Performance of the European Society of Cardiology 0/1-Hour, 0/2-Hour, and 0/3-Hour Algorithms for Rapid Triage of Acute Myocardial Infarction: An International Collaborative Meta-analysis

Cho-Han Chiang, Cho-Hung Chiang, John W. Pickering, Kiril M. Stoyanov, Derek P. Chew, Johannes T. Neumann, Francisco Ojeda, Nils A. Sörensen, Ke-Ying Su, Peter Kavsak, Andrew Worster, Kenji Inoue, Tonje R. Johannessen, Dan Atar, Michael Amann, Willibald Hochholzer, Arash Mokhtari, Ulf Ekelund, Raphael Twerenbold, Christian MuellerPhilipp Bahrmann, Nicolas Buttinger, Maureen Dooley, Onlak Ruangsomboon, Richard M. Nowak, Christopher R. DeFilippi, William F. Peacock, Tomas G. Neilan, Michael A. Liu, Wan Ting Hsu, Gin Hoong Lee, Pui-Un Tang, Kevin Sheng-Kai Ma, Dirk Westermann, Stefan Blankenberg, Evangelos Giannitsis, Martin P. Than, Chien-Chang Lee

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37 Citations (Scopus)


Background: The 2020 European Society of Cardiology (ESC) guidelines recommend using the 0/1-hour and 0/2-hour algorithms over the 0/3-hour algorithm as the first and second choices of high-sensitivity cardiac troponin (hs-cTn)–based strategies for triage of patients with suspected acute myocardial infarction (AMI). Purpose: To evaluate the diagnostic accuracies of the ESC 0/1-hour, 0/2-hour, and 0/3-hour algorithms. Data Sources: PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus from 1 January 2011 to 31 December 2020. (PROSPERO: CRD42020216479) Study Selection: Prospective studies that evaluated the ESC 0/1-hour, 0/2-hour, or 0/3-hour algorithms in adult patients presenting with suspected AMI. Data Extraction: The primary outcome was index AMI. Twenty unique cohorts were identified. Primary data were obtained from investigators of 16 cohorts and aggregate data were extracted from 4 cohorts. Two independent authors assessed each study for methodological quality. Data Synthesis: A total of 32 studies (20 cohorts) with 30 066 patients were analyzed. The 0/1-hour algorithm had a pooled sensitivity of 99.1% (95% CI, 98.5% to 99.5%) and negative predictive value (NPV) of 99.8% (CI, 99.6% to 99.9%) for ruling out AMI. The 0/2-hour algorithm had a pooled sensitivity of 98.6% (CI, 97.2% to 99.3%) and NPV of 99.6% (CI, 99.4% to 99.8%). The 0/3-hour algorithm had a pooled sensitivity of 93.7% (CI, 87.4% to 97.0%) and NPV of 98.7% (CI, 97.7% to 99.3%). Sensitivity of the 0/3-hour algorithm was attenuated in studies that did not use clinical criteria (GRACE score <140 and pain-free) compared with studies that used clinical criteria (90.2% [CI, 82.9 to 94.6] vs. 98.4% [CI, 88.6 to 99.8]). All 3 algorithms had similar specificities and positive predictive values for ruling in AMI, but heterogeneity across studies was substantial. Diagnostic performance was similar across the hs-cTnT (Elecsys; Roche), hs-cTnI (Architect; Abbott), and hs-cTnI (Centaur/Atellica; Siemens) assays. Limitation: Diagnostic accuracy, inclusion and exclusion criteria, and cardiac troponin sampling time varied among studies. Conclusion: The ESC 0/1-hour and 0/2-hour algorithms have higher sensitivities and NPVs than the 0/3-hour algorithm for index AMI.

Original languageEnglish
Number of pages23
JournalAnnals of internal medicine
Issue number1
Publication statusPublished - Jan 2022


  • Cardiology
  • Algorithms
  • Triage
  • Myocardial


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