Journal
EUROPEAN HEART JOURNAL
Volume 39, Issue 42, Pages 3780-3794Publisher
OXFORD UNIV PRESS
DOI: 10.1093/eurheartj/ehy514
Keywords
Age; High-sensitivity cardiac troponin; Guidelines; 0/1h-Algorithm; Diagnosis of AMI
Categories
Funding
- Swiss National Science Foundation
- Swiss Heart Foundation
- European Union
- Stiftung fur kardiovaskulare Forschung Basel
- University of Basel
- Abbott
- Beckman Coulter
- Brahms
- Roche
- Siemens
- Singulex
- KTI
- Biomerieux
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Aims We aimed to evaluate the impact of age on the performance of the European Society of Cardiology (ESC) 0/1h-algorithms and to derive and externally validate alternative cut-offs specific to older patients. Methods and results We prospectively enrolled patients presenting to the emergency department (ED) with symptoms suggestive of and results acute myocardial infarction in three large diagnostic studies. Final diagnoses were adjudicated by two independent cardiologists. High-sensitivity cardiac troponin (hs-cTn) T and I concentrations were measured at presentation and after 1 h. Patients were stratified according to age [<55 years (young), >= 55 to <70 years (middle-age), >= 70 years (old)]. Rule-out safety of the ESC hs-cTnT 0/1h-algorithm was very high in all age-strata: sensitivity 100% [95% confidence interval (95% CI) 94.9-100] in young, 99.3% (95% CI 96.0-99.9) in middle-age, and 99.3% (95% CI 97.599.8) in old patients. Accuracy of rule-in decreased with age: specificity 97.0% (95% CI 95.8-97.9) in young, 96.1% (95% CI 94.5-97.2) in middle-age, and 92.7% (95% CI 90.7-94.3) in older patients. Triage efficacy decreased with increasing age (young 93%, middle-age 80%, old 55%, P <0.001). Similar results were found for the ESC hs-cTnT 0/1h-algorithm. Alternative, slightly higher cut-off concentrations optimized for older patients maintained very high safety of rule-out, increased specificity of rule-in (P< 0.01), reduced overall efficacy for hs-cTnT (P <0.01), while maintaining efficacy for hs-cTnl. Findings were confirmed in two validation cohorts (n = 2767). Conclusion While safety of the ESC 0/1h-algorithms remained very high, increasing age significantly reduced overall efficacy and the accuracy of rule-in. Alternative slightly higher cut-off concentrations may be considered for older patients, particularly if using hs-cTnl.
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