Impact of age on the performance of the ESC 0/1h-algorithms for early diagnosis of myocardial infarction
Jasper Boeddinghaus, Thomas Nestelberger, Raphael Twerenbold, Johannes Tobias Neumann, Bertil Lindahl, Evangelos Giannitsis, Nils Arne Sörensen, Patrick Badertscher, Janina E Jann, Desiree Wussler, Christian Puelacher, Maria Rubini Giménez, Karin Wildi, Ivo Strebel, Jeanne Du Fay de Lavallaz, Farah Selman, Zaid Sabti, Nikola Kozhuharov, Eliska Potlukova, Katharina Rentsch, Òscar Miró, F Javier Martin-Sanchez, Beata Morawiec, Jiri Parenica, Jens Lohrmann, Wanda Kloos, Andreas Buser, Nicolas Geigy, Dagmar I Keller, Stefan Osswald, Tobias Reichlin, Dirk Westermann, Stefan Blankenberg, Christian Mueller, APACE, BACC, and TRAPID-AMI Investigators, Irina Klimmeck, Fausta Chiaverio, Esther Garrido, Joachim Gea, Helena Mañé Cruz, Carolina Isabel Fuenzalida Inostroza, Miguel Angel García Briñón, Samyut Shrestha, Dayana Flores, Michael Freese, Claudia Stelzig, Caroline Kulangara, Kathrin Meissner, Nicolas Schaerli, Deborah Mueller, Lorraine Sazgary, Stella Marbot, Beatriz López, Sofia Calderón, Esther Rodriguez Adrada, Damian Kawecki, Ewa Nowalany-Kozielska, Eva Ganovská, Arnold von Eckardstein, Isabel Campodarve, Michael Christ, Jorge Ordóñez-Llanos, Christopher R de Filippi, James McCord, Richard Body, Mauro Panteghini, Thomas Jernberg, Mario Plebani, Franck Verschuren, John K French, Robert Christenson, Silvia Weiser, Garnet Bendig, Peter Dilba, Jasper Boeddinghaus, Thomas Nestelberger, Raphael Twerenbold, Johannes Tobias Neumann, Bertil Lindahl, Evangelos Giannitsis, Nils Arne Sörensen, Patrick Badertscher, Janina E Jann, Desiree Wussler, Christian Puelacher, Maria Rubini Giménez, Karin Wildi, Ivo Strebel, Jeanne Du Fay de Lavallaz, Farah Selman, Zaid Sabti, Nikola Kozhuharov, Eliska Potlukova, Katharina Rentsch, Òscar Miró, F Javier Martin-Sanchez, Beata Morawiec, Jiri Parenica, Jens Lohrmann, Wanda Kloos, Andreas Buser, Nicolas Geigy, Dagmar I Keller, Stefan Osswald, Tobias Reichlin, Dirk Westermann, Stefan Blankenberg, Christian Mueller, APACE, BACC, and TRAPID-AMI Investigators, Irina Klimmeck, Fausta Chiaverio, Esther Garrido, Joachim Gea, Helena Mañé Cruz, Carolina Isabel Fuenzalida Inostroza, Miguel Angel García Briñón, Samyut Shrestha, Dayana Flores, Michael Freese, Claudia Stelzig, Caroline Kulangara, Kathrin Meissner, Nicolas Schaerli, Deborah Mueller, Lorraine Sazgary, Stella Marbot, Beatriz López, Sofia Calderón, Esther Rodriguez Adrada, Damian Kawecki, Ewa Nowalany-Kozielska, Eva Ganovská, Arnold von Eckardstein, Isabel Campodarve, Michael Christ, Jorge Ordóñez-Llanos, Christopher R de Filippi, James McCord, Richard Body, Mauro Panteghini, Thomas Jernberg, Mario Plebani, Franck Verschuren, John K French, Robert Christenson, Silvia Weiser, Garnet Bendig, Peter Dilba
Abstract
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://ichgcp.net/clinical-trials-registry/NCT00470587, number NCT00470587 and NCT02355457 (BACC).
Source: PubMed