Clin Res Cardiol (2023). https://doi.org/10.1007/s00392-023-02180-w
Prognostic impact of stepwise 0/1/3h rule-out of myocardial infarction using high-sensitivity troponin T
J. Lehmacher1, B. Toprak1, N. A. Sörensen1, L. Guo1, P. Haller1, A. Schock1, D. Westermann2, T. Hartikainen2, T. Zeller1, S. Blankenberg1, J. T. Neumann1, R. Twerenbold1, für die Studiengruppe: BACC
1Klinik für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg, Hamburg; 2Innere Medizin III, Kardiologie und Angiologie, Universitäts-Herzzentrum Freiburg - Bad Krozingen, Freiburg im Breisgau;
patients with suspected myocardial infarction (MI). These algorithms allow for rule-out or rule-in of MI at 0 and 1 hour (h), depending on the high-sensitivity cardiac troponin (hs-cTn) concentrations and changes. Recently, to reduce the proportion of patients remaining in the observe zone (≈30-40%), specific cut-offs to allow for 3-h rule-out have been derived for hs-cTnT. However, the prognostic implications of this newly suggested 3h rule-out option is unclear.

Objective: We aimed to compare the prognostic impact of the three rule-out options provided by the ESC at 0, 1 and 3 h for the composite endpoint of major adverse cardiac events (MACE) at 90 days and 3 years.

Methods: In this prospective cohort study, we included patients presenting with suspected MI to the emergency department of a German tertiary hospital. Concentrations of hs-cTnT were measured at presentation and after 1 and 3h. Final diagnosis was adjudicated according to the 4th Universal Definition of MI. Patients were followed-up via structured telephone interview assessing the endpoints of incident MACE was defined as a composite of cardiovascular death, non-fatal MI, cardiac rehospitalization and revascularization. We triaged patients into three rule-out categories applying the 0/1/3h algorithm (0h if 0h hs-cTnT <5ng/l AND symptom onset >3h, 1h if 0h hs-cTnT <12ng/l AND 0-1h delta <3ng/l, 3h if 3h hs-cTnT <15ng/l AND 0-3h delta <4ng/l). We computed survival curves for the predefined endpoint at 90 days and 3 years for each rule-out group. Further, we performed Cox regression analyses comparing the risk of MACE at 90 days and 3 years in patients ruled-out after 1 and 3 h compared to patients directly ruled-out at 0 h (reference).

Results: In 2515 patients, median age was 64 years and 63.6% were men. Application of the 0/1/3h algorithm ruled-out 371 (14.8%) patients at 0h, 961 (38.2%) after 1h, and 179 (7.1%) after 3h. Median follow-up was 4.59 years (4.51, 4.75) with a total of 733 patients experiencing MACE. Incidence of MACE was gradually higher in the rule-out groups at 1h and 3h as compared to 0h without reaching level of significance at 90 days (p=0.19), however at 3 years (rule-out 0h16.2%, rule-out 1h20.8%, rule-out 3h32.3%, p<0.001; Figure 1). In the Cox regression analyses at 3 years, patients ruled-out after 3h showed a significantly increased risk for MACE with a hazard ratio of 2.11 (1.44, 3.08, p<0.001) compared to patients ruled-out at 0h (Table 1).

Conclusion: Application of the 0/1/3h algorithm for triage of patients with suspected MI harbors predictive value regarding long-term prognosis, with patients ruled-out after 3h showing significantly higher risk of MACE over three years as compared to rule-out after 0h and 1h.



Table 1: Cox regression for 90-day and 3-year MACE

 

HR (95% CI) MACE

p-value

 

90 days

Rule-out 0h

Reference

 

Rule-out 1h

1.41 (0.83, 2.37)

0.20

Rule-out 3h

1.87 (0.94, 3.71)

0.074

3 years

Rule-out 0h

Reference

 

Rule-out 1h

1.33 (0.99, 1.78)

0.062

Rule-out 3h

2.11 (1.44, 3.08)

<0.001

 

Cox regression models for 90-day and 3-year risk of major adverse cardiac events (MACE) in patients ruled-out after 1 hour and 3 hours with patients directly ruled-out at 0 hour serving as reference group. HR = hazard ratio, CI = confidence interval,



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