Diagnostic performance of ESC's chest pain algorithm not up to mark in those with known CAD

A recent study published in JAMA Cardiology found that the ESC 0/1-hour hs-cTnT algorithm could not safely exclude 30-day cardiac death or myocardial infarction (MI) among patients with chest pain having coronary artery disease (CAD).

"Our findings suggest clinicians should be cautious of the algorithm used in patients with known CAD. The negative predictive value was significantly higher in patients without a history of CAD but remained less than 99%," the researchers wrote.

Considering the limited data on the performance of the ESC 0/1-hour hs-cTnT algorithm in patients with known CAD (prior MI, ≥70% coronary stenosis, or coronary revascularization), Nicklaus P. Ashburn and colleagues from the US aimed to evaluate and compare the diagnostic performance of the algorithm for 30-day MI or cardiac death among patients with and without known CAD. They also determined if the algorithm could achieve the negative predictive value rule-out threshold of 99% or higher.

For this purpose, the researchers conducted a preplanned subgroup analysis of STOP-CP, a prospective multisite cohort study conducted from 2017 to 2018 at eight EDs in the US. It included patients aged 21 years or older with symptoms indicating acute coronary syndrome without ST-segment elevation on initial electrocardiogram.

Participants with 0- and 1-hour hs-cTnT measures were stratified into observation, rule-out, and rule-in zones using the ESC 0/1-hour hs-cTnT algorithm. Expert adjudicators determined myocardial infarction or cardiac death at 30 days.

The study led to the following findings:

• During the study period, 1430 patients were accrued. In the cohort, 54.2% were male, and the mean age was 57.6 years.
• At 30 days, cardiac death or MI occurred in 12.8% of participants. Known CAD was present in 31.4%.
• Among patients with known CAD, the ESC 0/1-hour algorithm classified 39.6% into the rule-out zone compared with 66.1% without CAD.
• Among rule-out zone patients, 30-day cardiac death or MI occurred in 3.4% of patients with known CAD and 1.1% without CAD.
• The negative predictive value for 30-day MI or cardiac death was 96.6% among patients with known CAD and 98.9% without known CAD.

"The ESC 0/1-hour hs-cTnT algorithm could not safely exclude 30-day myocardial infarction or cardiac death in patients with known coronary artery disease," the researchers wrote. "This suggests clinicians should be cautious of using the algorithm in patients with known CAD."

The negative predictive value was notably higher in patients without a CAD history but remained less than 99%.

Reference:

Ashburn NP, Snavely AC, O'Neill JC, et al. Performance of the European Society of Cardiology 0/1-Hour Algorithm With High-Sensitivity Cardiac Troponin T Among Patients With Known Coronary Artery Disease. JAMA Cardiol. Published online March 01, 2023. doi:10.1001/jamacardio.2023.0031