Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.
Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway.
Eur Heart J Acute Cardiovasc Care. 2021 May 11;10(3):287-301. doi: 10.1093/ehjacc/zuaa016.
Troponin-based algorithms are made to identify myocardial infarctions (MIs) but adding either standard acute coronary syndrome (ACS) risk criteria or a clinical risk score may identify more patients eligible for early discharge and patients in need of urgent revascularization.
Post-hoc analysis of the WESTCOR study including 932 patients (mean 63 years, 61% male) with suspected NSTE-ACS. Serum samples were collected at 0, 3, and 8-12 h and high-sensitivity cTnT (Roche Diagnostics) and cTnI (Abbott Diagnostics) were analysed. The primary endpoint was MI, all-cause mortality, and unplanned revascularizations within 30 days. Secondary endpoint was non-ST-elevation myocardial infarction (NSTEMI) during index hospitalization. Two combinations were compared: troponin-based algorithms (ESC 0/3 h and the High-STEACS algorithm) and either ACS risk criteria recommended in the ESC guidelines, or one of eleven clinical risk scores, HEART, mHEART, CARE, GRACE, T-MACS, sT-MACS, TIMI, EDACS, sEDACS, Goldman, and Geleijnse-Sanchis. The prevalence of primary events was 21%. Patients ruled out for NSTEMI and regarded low risk of ACS according to ESC guidelines had 3.8-4.9% risk of an event, primarily unplanned revascularizations. Using HEART score instead of ACS risk criteria reduced the number of events to 2.2-2.7%, with maintained efficacy. The secondary endpoint was met by 13%. The troponin-based algorithms without evaluation of ACS risk missed three-index NSTEMIs with a negative predictive value (NPV) of 99.5% and 99.6%.
Combining ESC 0/3 h or the High-STEACS algorithm with standardized clinical risk scores instead of ACS risk criteria halved the prevalence of rule-out patients in need of revascularization, with maintained efficacy.
肌钙蛋白为基础的算法旨在识别心肌梗死（MI），但增加标准急性冠状动脉综合征（ACS）风险标准或临床风险评分可能会识别出更多适合早期出院和需要紧急血运重建的患者。
对疑似非 ST 段抬高型急性冠脉综合征（NSTE-ACS）的 WESTCOR 研究进行了事后分析，纳入了 932 例患者（平均年龄 63 岁，61%为男性）。在 0、3 和 8-12 小时采集血清样本，并分析高敏肌钙蛋白 T（罗氏诊断公司）和肌钙蛋白 I（雅培诊断公司）。主要终点是 30 天内的 MI、全因死亡率和计划外血运重建。次要终点是住院期间的非 ST 段抬高型心肌梗死（NSTEMI）。比较了两种组合：肌钙蛋白为基础的算法（ESC 0/3 h 和 High-STEACS 算法）和 ESC 指南推荐的 ACS 风险标准，或 11 种临床风险评分中的一种，包括 HEART、mHEART、CARE、GRACE、T-MACS、sT-MACS、TIMI、EDACS、sEDACS、Goldman 和 Geleijnse-Sanchis。主要事件的发生率为 21%。根据 ESC 指南排除 NSTEMI 并被认为 ACS 风险低的患者，发生事件的风险为 3.8-4.9%，主要为计划外血运重建。使用 HEART 评分而不是 ACS 风险标准可将事件数量减少至 2.2-2.7%，同时保持疗效。次要终点的发生率为 13%。不评估 ACS 风险的基于肌钙蛋白的算法漏诊了 3 例阴性预测值（NPV）为 99.5%和 99.6%的索引 NSTEMI。
将 ESC 0/3 h 或 High-STEACS 算法与标准化临床风险评分相结合，而不是 ACS 风险标准，可将需要血运重建的排除患者的患病率减半，同时保持疗效。
