Rapid diagnosis of acute myocardial infarction

Abstract

Over the last decade, intense collaboration between physician scientists and the diagnostic industry has enabled game-changing innovation in the rapid diagnosis of acute myocardial infarction (AMI). (1–12) High sensitivity cardiac troponin (hs-cTn) assays enable reliable measurement of cardiac troponin (cTn) concentrations in the normal range, thereby increasing substantially the diagnostic accuracy for AMI already with the first blood drawn at presentation to the emergency department (ED). (1–12) This was a prerequisite for the development and maturation of early rule-out and rulein strategies for AMI into clinical practice worldwide. While the first iteration was complex and required the combination of a biomarker panel, the electrocardiogram, and a clinical risk score, allowing the safe ruleout of AMI in only 10% of patients with acute chest pain, the latest iterations including the European Society of Cardiology (ESC) 0/1h-algorithm are simple, as they are based on hs-cTn concentrations only, and allow the safe rule-out AND/OR rule-in of AMI in about 75% of patients. (13-21) The ESC 0/1h-algorithm is a combination of the single measurement approach with the original 0/1halgorithm. (5, 7, 22–25) It has all the advantages of the single measurement approach (speed and simplicity), but further extends the number of patients eligible for triage towards rule-out of AMI to those patients with low hs-cTnT/I concentrations at presentation and NO relevant change (rise AND/OR fall) in hs-cTnT/I concentrations after 1 h. It also adds the possibility to triage patients towards rule-in of AMI using high initial hs-cTnT/I concentrations and/or relevant changes in hs-cTnT/I after 1 h. The ESC 0/1h-algorithm has been derived and validated for all currently available hs-cTnT/I assays, with unique data-driven cut-off values for each assay to achieve a sensitivity and negative predictive value of 99% or higher. (5, 7, 22–26) It is recommended by the ESC guideline for the management of acute coronary syndromes in patients without