A Common Algorithm for Cardiac Troponin to Rule Out and Rule in Acute Myocardial Infarction.

Summary

In 5,011 ED patients with suspected MI across three hs-cTn assays, a common change-criteria (3C) algorithm achieved diagnostic accuracy comparable to ESC rule-in/rule-out pathways. 3C improved operational effectiveness for hs-cTnI (83–89% vs 64–75% for ESC) and ruled-in some MIs that ESC algorithms ruled out, while remaining assay-agnostic and sampling-interval independent.

Key Findings

• Across 5,011 patients (MI prevalence 16.1%), 3C had sensitivity/specificity comparable to ESC algorithms.
• 3C improved effectiveness for hs-cTnI (83.2–88.8%) versus ESC (64.4–74.5%) but not for hs-cTnT.
• 3C ruled in additional MI cases that ESC pathways ruled out, without dependence on sampling interval.

Clinical Implications

Hospitals can consider implementing the 3C algorithm as an assay-agnostic alternative to ESC pathways, especially when multiple hs-cTn platforms are in use. Expect operational benefits for hs-cTnI; validate locally for hs-cTnT where effectiveness was not superior.

Limitations

• Not a randomized comparison; potential contextual and workflow differences across sites
• hs-cTnT effectiveness was not superior to ESC; external validation needed across vendors

Future Directions

Prospective implementation studies assessing time-to-decision, ED throughput, and clinical outcomes across diverse hs-cTn platforms; vendor-specific calibration and health-economic evaluations.