Comparison of the European Society of Cardiology 0/1-Hour and High-Sensitivity Troponin in the Evaluation of Patients With Suspected Acute Coronary Syndrome 0/2-or-0/3-Hour Algorithms for Rapid Myocardial Infarction Diagnosis: A Prospective Multicenter Study - Glaeser, J.; Lopez-Ayala, P.; Kellner, C.; Boeddinghaus, J.; Nestelberger, T.; Koechlin, L.; Sorensen, N. A.; Haller, P. M.; Bima, P.; Crisanti, L.; Spagnuolo, C. C.; Strebel, I.; et al. (J Am Coll Cardiol, 2026)
BACKGROUND: The optimal approach for the early diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI) remains uncertain, because no large trials have been performed. Accordingly, guideline recommendations differ and do not overall give a clear answer. OBJECTIVES: The authors aimed to directly compare the European Society of Cardiology 0/1-hour algorithm (ESC 0/1h-algorithm) and the high-sensitivity troponin in the evaluation of patients with acute coronary syndrome 0/2-hour or 0/3-hour pathway (High-STEACS 0/2h-0/3h-pathway) in patients presenting with acute chest discomfort. METHODS: This prospective, international, multicenter, diagnostic study enrolled patients presenting to the emergency department with acute chest discomfort. Final diagnoses were centrally adjudicated by 2 independent cardiologists. The primary diagnostic endpoint was NSTEMI type 1. Both algorithms were applied in parallel using 3 high-sensitivity cardiac troponin (hs-cTn) assays: hs-cTnI-Architect, hs-cTnI-Centaur/Atellica, and hs-cTnT-Elecsys. The findings were externally validated in an independent prospective diagnostic study. RESULTS: Among 4,663 eligible patients (median age: 61 years; 32% women), 663 (14.2%) had NSTEMI type 1. The ESC 0/1h-algorithm had higher sensitivity when using hs-cTnI-Architect (100% [95% CI: 99.4-100]) compared with the High-STEACS 0/2h-pathway (98.1% [95% CI: 96.7-99], P < 0.001), but the proportion of patients assigned to the rule-out group was lower (52% vs 72.5%, P < 0.001). Differences were similar but were less pronounced for hs-cTnI-Centaur/Atellica and absent for hs-cTnT-Elecsys. Specificity was consistently higher for the ESC 0/1h-algorithms vs the High-STEACS 0/2h-0/3h-pathways for all hs-cTnT/I-assays. These findings were confirmed when using High-STEACS 0/3h-pathways and in the external validation cohort (n = 2,485; median age: 64 years; 37% women). CONCLUSIONS: Overall, both algorithms exhibited comparable and excellent performance. When using hs-cTnI, the ESC-0/1h-algorithms showed higher sensitivity, whereas the High-STEACS 0/2h-0/3h-pathways demonstrated higher efficacy. Consistently, the ESC 0/1h-algorithms showed higher specificity for NSTEMI. These findings provide direct, validated evidence to guide hospitals in selecting an hs-cTn pathway aligned with their clinical and operational priorities. (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE] Study [APACE], NCT00470587; Biomarkers in Acute Cardiac Care [BACC], NCT02355457).
Keywords: journalArticle; (P400PM_180828) as well as speaker/consulting honoraria from Abbott, Ortho; *Acute Coronary Syndrome/diagnosis/blood; *Algorithms; *Myocardial Infarction/diagnosis/blood; *Non-ST Elevated Myocardial Infarction/diagnosis/blood; *Troponin I/blood; *Troponin T/blood; Aged; AstraZeneca, Bayer, Boehringer Ingelheim, Inari, Medtronic, Merck, ReCor Medical,; Bangerter-Rhyner Foundation, and the "Freiwillige Akademische Gesellschaft Basel"; Bayer, Ortho Clinical Diagnostics, and Orion Pharma, outside the submitted work; Biomarkers/blood; Clinical Diagnostics, Roche, and Siemens, outside the submitted work. Dr Wildi; Corporation, Novartis, Ortho Diagnostics, Quidel, Roche, Siemens, SpinChip,; Deutsche Forschungsgemeinschaft (SFB TRR219, Project-ID 322900939), and Deutsche; Division of Internal Medicine, Swiss Academy of Medical Sciences, Gottfried and; Dr Koechlin has received a research grant from the Swiss Heart Foundation,; ESC 0/1h-algorithm; Europe; Female; Foundation (FF20079, FF21103 and FF24149) and speaker's honoraria from Quidel,; Foundation (P400PM_191037/1), Prof Dr Max Cloetta Foundation, Margarete und; German Heart Research Foundation and an unrestricted grant from Roche. The; Heart Foundation and has received honoraria from Siemens, Roche Diagnostics,; Heart Foundation, University Hospital Basel, University of Basel, Abbott, Astra; Herzstiftung; Humans; Idorsia, LSI Medience Corporation, Ortho Clinical Diagnostics, Quidel, Roche,; Ingelheim, BMS, Idorsia, Novartis, Osler, Roche, SpinChip, and Sanofi, all paid; Julia Bangerter-Rhyner Foundation, Swiss National Science Foundation, and Swiss; Mahfoud has received research grants from Deutsche Gesellschaft fur Kardiologie,; Male; Middle Aged; National Science Foundation (grant no. P300PB_167803), Swiss Heart Foundation,; Nestelberger has received research support from the Swiss National Science; Ortho Clinical Diagnostics, Quidel Corporation, and Beckman Coulter and travel; Pronova Medical, Meril, Boston Scientific, Medtronic, Abbott, Beckman Coulter,; Prospective Studies; Research, and German Research Foundation. Dr Rubini Gimenez has received research; Roche Diagnostics, and Polymedco in the last 36 months, all outside the submitted; Servier, and Terumo. Dr Twerenbold reports research support from the Swiss; Siemens), who had no role in the design of the study, analysis of the data,; Siemens, Singulex, and SpinChip Diagnostics. The BACC study was supported by the; Siemens, Singulex, and Thermo Fisher. Dr Neumann reports speaker; Singulex, and Sphingotec, outside the submitted work, as well as; Societies, Medical; Swiss Society of Cardiology, and Cardiovascular Research Foundation Basel and; Time Factors; Twerenbold and Neumann are listed as co-inventors of an international patent on; University Hospital Basel, University of Basel, Abbott, Beckman Coulter, Brahms,; University of Basel, Swiss Academy of Medical Sciences, Gottfried and Julia; Walter Lichtenstein-Stiftung (3MS1038), and University Hospital Basel as well as; Zeneca, Beckman Coulter, Boehringer Ingelheim, Brahms, Idorsia, LSI Medience; and he has; and research grants from the University of Basel, University Hospital of Basel,; as well as speaker honoraria from Roche Diagnostics, Abbott, and Siemens, paid to; co-founders and shareholders of the ART-EMIS Hamburg GmbH. Dr Mueller reports; external validation; from the German Center of Cardiovascular Research (DZHK) and research support by