Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland.
GREAT Network, Rome, Italy.
Clin Chem. 2021 Jan 8;67(1):114-123. doi: 10.1093/clinchem/hvaa226.
Over the past decade, intense collaboration between academic investigators and the diagnostic industry have allowed the integration of high-sensitivity cardiac troponin (hs-cTn) assays into clinical practice worldwide. The hs-cTn assays, with their increased diagnostic accuracy for acute myocardial infarction (AMI), have facilitated the maturation of early rule-out strategies. The first iteration was complex and required the combination of a biomarker panel, the electrocardiogram, and a clinical risk score and allowed the safe rule-out of AMI in only 10% of patients with acute chest pain. In contrast, the latest iterations, including the European Society of Cardiology (ESC) 0/1-h algorithm, are simple. They are based on hs-cTn concentrations only and allow the safe rule-out or rule-in of AMI in up to 75% of patients.
The purposes of this minireview are (a) to describe the best validated hs-cTn-based strategies for early rule-out of AMI, (b) to discuss the advantages and limitations of the different strategies, (c) to identify patient subgroups requiring particular attention, (d) to recognize challenges for widespread clinical implementation, and (e) to provide guidance on strategies for their safe and effective clinical implementation.
Physicians and institutions may choose among several well-validated rule-out algorithms. The ESC 0/1-h algorithm for hs-cTnT or hs-cTnI seems to be the most attractive option today. It best balances safety and efficacy, and it has been derived and validated for all currently available hs-cTnT/I assays, facilitating widespread clinical implementation.
在过去的十年中，学术研究人员与诊断行业之间的紧密合作使得高敏心肌肌钙蛋白（hs-cTn）检测在全球范围内被纳入临床实践。hs-cTn 检测在急性心肌梗死（AMI）诊断中的准确性更高，推动了早期排除策略的成熟。第一代策略较为复杂，需要结合生物标志物谱、心电图和临床风险评分，仅能对 10%的急性胸痛患者安全排除 AMI。相比之下，最新一代策略，包括欧洲心脏病学会（ESC）0/1-h 算法，较为简单，仅基于 hs-cTn 浓度，可对多达 75%的患者安全排除或诊断 AMI。
本文旨在（a）描述经充分验证的基于 hs-cTn 的 AMI 早期排除的最佳策略，（b）讨论不同策略的优缺点，（c）明确需要特别关注的患者亚组，（d）识别广泛临床应用面临的挑战，（e）提供安全有效实施策略的指导。
医生和医疗机构可以在几种经过充分验证的排除算法中进行选择。ESC 基于 hs-cTnT 或 hs-cTnI 的 0/1-h 算法似乎是目前最有吸引力的选择。该算法在安全性和有效性之间取得了最佳平衡，并且已经针对所有当前可用的 hs-cTnT/I 检测方法进行了推导和验证，有助于广泛的临床应用。
