Impact of age on the performance of the ESC 0/1h-algorithms for early diagnosis of myocardial infarction

• Published in: European heart journal Vol. 39; no. 42; pp. 3780 - 3794
• Main Authors: Boeddinghaus, Jasper, Nestelberger, Thomas, Twerenbold, Raphael, Neumann, Johannes Tobias, Lindahl, Bertil, Giannitsis, Evangelos, Sörensen, Nils Arne, Badertscher, Patrick, Jann, Janina E, Wussler, Desiree, Puelacher, Christian, Rubini Giménez, Maria, Wildi, Karin, Strebel, Ivo, Du Fay de Lavallaz, Jeanne, Selman, Farah, Sabti, Zaid, Kozhuharov, Nikola, Potlukova, Eliska, Rentsch, Katharina, Miró, Òscar, Martin-Sanchez, F Javier, Morawiec, Beata, Parenica, Jiri, Lohrmann, Jens, Kloos, Wanda, Buser, Andreas, Geigy, Nicolas, Keller, Dagmar I, Osswald, Stefan, Reichlin, Tobias, Westermann, Dirk, Blankenberg, Stefan, Mueller, Christian
• Format: Journal Article
• Language: English
• Published: England Oxford University Press 07-11-2018
• Subjects: 0/1h-Algorithm; Age; Diagnosis of AMI; Guidelines; High-sensitivity cardiac troponin; 0/1h-Algorithm; Diagnosis of AMI; High-sensitivity cardiac troponin; Age; Guidelines
• ISSN: 0195-668X; 1522-9645; 1522-9645
• DOI: 10.1093/eurheartj/ehy514

Abstract
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 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 97.5–99.8) 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-cTnI. 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-cTnI.
Clinical Trial Registration
https://clinicaltrials.gov/ct2/show/NCT00470587, number NCT00470587 and NCT02355457 (BACC).