The ESC 2023 -0h/1h High-Sensitivity Cardiac Troponin Algorithm: Clinical Use, Evidence, and Challenges
The ESC 2023 -0h/1h High-Sensitivity Cardiac Troponin Algorithm: Clinical Use, Evidence, and Challenges
Source:
Revista Española de Cardiología (Rev Esp Cardiol), 2023
The basis for the ESC accelerated diagnostic algorithm for acute coronary syndromes (ACS) — particularly the 0/1-hour algorithm — lies in the well-established pathophysiology of myocardial infarction (MI):
With MI, levels of cardiac troponin (cTn) rise rapidly — typically within 1 hour when using high-sensitivity assays — following symptom onset, and remain elevated for a variable period of time, usually lasting several days.
Clinical implication:
Faster protocols (such as the ESC 0/1-hour algorithm), which rely on lower high-sensitivity troponin thresholds, may offer greater efficiency and safety in ruling out myocardial infarction compared to the traditional ESC 0/3-hour protocol.
Key Points Summary:
1. Diagnosis of NSTEMI-ACS relies on 3 elements: clinical assessment, ECG, and cardiac troponin (T/I).
2. High-sensitivity troponin (hs-cTn) assays allow faster detection of myocardial injury and earlier diagnosis.
3. Rapid ESC diagnostic algorithms using serial hs-cTn (0h/1h, 0h/2h, and 0h/3h) are recommended.
4. ESC 0h/1h algorithm is the preferred and most validated method (Class I recommendation).
5. This strategy triages patients into:
• Rule-out (very low baseline and no delta at 1h)
• Rule-in (high baseline or significant delta at 1h)
• Observe (intermediate or unclear changes)
6. Absolute delta is central: a significant rise or fall within 1h improves diagnostic accuracy.
7. Assay-specific cutoffs must be applied exactly as validated (Roche, Abbott, Siemens, etc.).
8 In the rule-out zone, patients presenting >3 hours after symptom onset with very low hs-cTn concentrations may be eligible for early discharge, provided there is no other clinical indication for hospital admission. .
9. In the rule-in zone, patients should undergo early coronary angiography and intensive care.
10. Observe zone patients require 3h troponin, echo, and possible coronary imaging.
11. The algorithm is a triage tool, not a discharge decision; clinical context remains essential.
12. Successful implementation depends on:
• Nursing team training
• Accurate timing and documentation of blood draws
. Clinical practice favors the use of absolute hs-cTn values or changes over relative values or percentage changes (e.g., 20–30%), as absolute deltas are easier to interpret and apply. Reichlin et al. and others have shown that absolute changes offer better diagnostic accuracy across various time intervals.
13. The 0h/2h algorithm is a validated alternative if the 1h sample is missed.