High-sensitivity cardiac troponin T (hs-cTnT) 0-hour/1-hour algorithm

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The high-sensitivity cardiac troponin T (hs-cTnT) 0-hour/1-hour algorithm uses hs-cTnT blood concentration at presentation and its absolute 1h change to stratify patients suspected of acute myocardial infarction.

The Calculator is intended to be used for patients presenting to the Emergency Department with Chest Pain aged 18 years or older.

Research authors: Reichlin T, Schindler C, Drexler B, Twerenbold R, Reiter M, Zellweger C, Moehring B, Ziller R, Hoeller R, Gimenez MR, Haaf P, Potocki M, Wildi K, Balmelli C, Freese M, Stelzig C, Freidank H, Osswald S, and Mueller C.

Version: 1.44

Public
Cardiology
{{ modelType }}

V-1.44-2426.24.05.31

(01)08719327522776(8012)v1.44(4326)240531(240)2426

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Absolute change of hs-cTnT:

ng/L within the first hour

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Absolute change of hs-cTnT: ng/L within the first hour

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Model performance:
The high-sensitivity cardiac troponin T(hs-cTnT) 0-hour/1-hour algorithm was reported to achieve a very high negative predictive value for acute myocardial infarction in the rule-out zone, to achieve a high positive predictive value in the rule-in zone, and to be very effective by triaging approximately 75% of patients presenting with suspected acute myocardial infarction to the ED to either rule-out or rule-in classifications.^1,2

In 2016, the algorithm was further validated by Mueller et al. in an external mulicenter cohort of 1,282 patients with a 17% rate of acute myocardial infarction.³ Use of hs-cTn assays at presentation and 1 hour later in classified 63% of patients as having no acute myocardial infarction, with a 99.1% NPV (95% CI 98.2% to 99.7%); 14% as having acute myocardial infarction, with a PPV of 77% (95% CI 70.4% to 83.0%); and 22.5% as having an indeterminate classification after 1 hour of testing.

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Calculations alone should never dictate patient care, and are no substitute for professional judgement. See our full disclaimer.

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Model author

Evidencio.Medical.Devices

Model ID

10439

Version

1.44

Revision date

2024-05-31

Specialty

Cardiology , Emergency medicine , Intensive care

Model type

Custom model ^{(Calculation)}

MeSH terms

ST Elevation Myocardial Infarction

Troponin C

Clinical Decision-Making

Status

Public

Formula

Study characteristics

Additional information

Background: High-sensitivity cardiac troponin (hs-cTn) assays seem to improve the early diagnosis of acute myocardial infarction (AMI), but it is unknown how to best use them in clinical practice. Our objective was to develop and validate an algorithm for rapid rule-out and rule-in of AMI.

Methods: A prospective multicenter study enrolling 872 unselected patients with acute chest pain presenting to the emergency department. High-sensitivity cardiac troponin T (hs-cTnT) was measured in a blinded fashion at presentation and after 1 hour. The final diagnosis was adjudicated by 2 independent cardiologists. An hs-cTnT algorithm incorporating baseline values as well as absolute changes within the first hour was derived from 436 randomly selected patients and validated in the remaining 436 patients. The primary prognostic end point was death during 30 days of follow-up.

Results: Acute myocardial infarction was the final diagnosis in 17% of patients. After applying the hs-cTnT algorithm developed in the derivation cohort to the validation cohort, 259 patients (60%) could be classified as “rule-out,” 76 patients (17%) as “rule-in,” and 101 patients (23%) as in the “observational zone” within 1 hour. Overall, this resulted in a sensitivity and negative predictive value of 100% for rule-out, a specificity and positive predictive value of 97% and 84%, respectively, for rule-in, and a prevalence of AMI of 8% in the observational zone group. Cumulative 30-day survival was 99.8%, 98.6%, and 95.3% (P < .001) in patients classified as rule-out, observational zone, and rule-in, respectively.

Conclusions: Using a simple algorithm incorporating hs-cTnT baseline values and absolute changes within the first hour allowed a safe rule-out as well as an accurate rule-in of AMI within 1 hour in 77% of unselected patients with acute chest pain. This novel strategy may obviate the need for prolonged monitoring and serial blood sampling in 3 of 4 patients.

Reference:
Reichlin T, Schindler C, Drexler B, et al. One-hour rule-out and rule-in ofacute myocardial infarction using high-sensitivity cardiac troponin T. Arch Intern Med. 2012;172:1211-1218.

Study Population

Total population size: 436

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Continuous characteristics

Name	LL	Q1	Median	Q3	UL	Unit
Age		52	65	75		years
Creatinine clearance		69	89	106		mL/min/m2

Categorical characteristics

Name	Subset / Group	Nr. of patients
Hypertension	Yes	295
Hypertension	No	141
Hypercholesterolemia	Yes	205
Hypercholesterolemia	No	231
Diabetes	Yes	87
Diabetes	No	349
Current smoking	Yes	107
Current smoking	No	329
Coronary artery disease	Yes	164
Coronary artery disease	No	272
Previous myocardial infarction	Yes	116
Previous myocardial infarction	No	320
Previous revascularization	Yes	124
Previous revascularization	No	312
Peripheral artery disease	Yes	26
Peripheral artery disease	No	410
Previous stroke	Yes	27
Previous stroke	No	409
Final diagnosis of AMI	Yes	75
Final diagnosis of AMI	No	361

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V-1.44-2426.24.05.31

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Absolute change of hs-cTnT: ng/L within the first hour

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Study Population

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	Evidencio B.V., Irenesingel 19, 7481 GJ Haaksbergen, The Netherlands
	V-1.44-2426.24.05.31
	(01)08719327522776(8012)v1.44(4326)240531(240)2426
	Decomplix AG, Freiburgstrasse 3, 3010 Bern, Switzerland
	Download the User manual
	Medical device