Background The European Society of Cardiology (ESC) rule-out algorithms use cutoffs optimized for exclusion of non-ST elevation myocardial infarction (NSTEMI). We investigated these and several novel algorithms for the rule-out of non-ST elevation acute coronary syndrome (NSTE-ACS) including less urgent coronary ischemia. Method A total of 1504 unselected patients with suspected NSTE-ACS were included and divided into a derivation cohort (n = 988) and validation cohort (n = 516). The primary endpoint was the diagnostic performance to rule-out NSTEMI and unstable angina pectoris during index hospitalization. The secondary endpoint was combined MI, all-cause mortality (within 30 days) and urgent (24 h) revascularization. The ESC algorithms for high-sensitivity cardiac troponin T (hs-cTnT) and I (hs-cTnI) were compared to different novel low-baseline (limit of detection), low-delta (based on the assay analytical and biological variation), and 0–1-h and 0–3-h algorithms. Results The prevalence of NSTE-ACS was 24.8%, 60.0% had noncardiac chest pain, and 15.2% other diseases. The 0–1/0–3-h algorithms had superior clinical sensitivity for the primary endpoint compared to the ESC algorithm (validation cohort); hs-cTnT: 95% vs 63%, and hs-cTnI: 87% vs 64%, respectively. Regarding the secondary endpoint, the algorithms had similar clinical sensitivity (100% vs 94%–96%) but lower clinical specificity (41%–19%) compared to the ESC algorithms (77%–74%). The rule-out rates decreased by a factor of 2–4. Conclusion Low concentration/low-delta troponin algorithms improve the clinical sensitivity for a combined endpoint of NSTEMI and unstable angina pectoris, with the cost of a substantial reduction in total rule-out rate. There was no clear benefit compared to ESC for diagnosing high-risk events.

中文翻译：

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新型肌钙蛋白算法排除非 ST 段抬高急性冠状动脉综合征的诊断性能

背景 欧洲心脏病学会 (ESC) 排除算法使用为排除非 ST 段抬高心肌梗死 (NSTEMI) 而优化的截止值。我们研究了这些和几种新的排除非 ST 段抬高急性冠状动脉综合征 (NSTE-ACS) 的算法，包括不太紧急的冠状动脉缺血。方法 共纳入 1504 例未选择的疑似 NSTE-ACS 患者，并分为推导队列（n = 988）和验证队列（n = 516）。主要终点是在住院期间排除 NSTEMI 和不稳定型心绞痛的诊断性能。次要终点是心肌梗死、全因死亡率（30 天内）和紧急（24 小时）血运重建。将高灵敏度心肌肌钙蛋白 T (hs-cTnT) 和 I (hs-cTnI) 的 ESC 算法与不同的新型低基线（检测限）、低增量（基于测定分析和生物学变异）进行比较，和 0-1-h 和 0-3-h 算法。结果NSTE-ACS的患病率为24.8%，60.0%为非心源性胸痛，15.2%为其他疾病。与 ESC 算法（验证队列）相比，0-1/0-3-h 算法对主要终点具有更高的临床敏感性；hs-cTnT：95% 对 63%，hs-cTnI：87% 对 64%。关于次要终点，与 ESC 算法 (77%-74%) 相比，算法具有相似的临床敏感性 (100% 对 94%–96%)，但临床特异性较低 (41%–19%)。排除率下降了 2-4 倍。结论 低浓度/低 delta 肌钙蛋白算法提高了 NSTEMI 和不稳定型心绞痛联合终点的临床敏感性，但总排除率显着降低。与 ESC 相比，在诊断高危事件方面没有明显的优势。