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

TY - JOUR

T1 - Impact of age on the performance of the ESC 0/1h-algorithms for early diagnosis of myocardial infarction

AU - Boeddinghaus, Jasper

AU - Nestelberger, Thomas

AU - Twerenbold, Raphael

AU - Neumann, Johannes Tobias

AU - Lindahl, Bertil

AU - Giannitsis, Evangelos

AU - Sörensen, Nils Arne

AU - Badertscher, Patrick

AU - Jann, Janina E

AU - Wussler, Desiree

AU - Puelacher, Christian

AU - Rubini Giménez, Maria

AU - Wildi, Karin

AU - Strebel, Ivo

AU - Du Fay de Lavallaz, Jeanne

AU - Selman, Farah

AU - Sabti, Zaid

AU - Kozhuharov, Nikola

AU - Potlukova, Eliska

AU - Rentsch, Katharina

AU - Miró, Òscar

AU - Martin-Sanchez, F Javier

AU - Morawiec, Beata

AU - Parenica, Jiri

AU - Lohrmann, Jens

AU - Kloos, Wanda

AU - Buser, Andreas

AU - Geigy, Nicolas

AU - Keller, Dagmar I

AU - Osswald, Stefan

AU - Reichlin, Tobias

AU - Westermann, Dirk

AU - Blankenberg, Stefan

AU - Mueller, Christian

AU - APACE, BACC, and TRAPID-AMI Investigators

PY - 2018/11/7

Y1 - 2018/11/7

N2 - 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).

AB - 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).

KW - Adult

KW - Age Factors

KW - Aged

KW - Algorithms

KW - Early Diagnosis

KW - Female

KW - Humans

KW - Male

KW - Middle Aged

KW - Myocardial Infarction/diagnosis

KW - Practice Guidelines as Topic

KW - Prospective Studies

KW - Sensitivity and Specificity

KW - Troponin/blood

U2 - 10.1093/eurheartj/ehy514

DO - 10.1093/eurheartj/ehy514

M3 - SCORING: Journal article

C2 - 30169752

VL - 39

SP - 3780

EP - 3794

JO - EUR HEART J

JF - EUR HEART J

SN - 0195-668X

IS - 42

ER -