Diagnostic Accuracy and Safety of High-Sensitivity Troponin Algorithms for Early Exclusion of Acute Coronary Syndrome

Abstract

Background:
High-sensitivity cardiac troponin (hs-cTn) algorithms are increasingly used to rapidly exclude acute coronary syndrome (ACS) in emergency departments, but their diagnostic accuracy, safety and effects on patient flow remain uncertain.
Methods:
Electronic databases were searched from inception to August 2024 for prospective cohorts and trials of adults with suspected ACS managed using predefined hs-cTn accelerated diagnostic pathways. Studies had to report diagnostic accuracy for myocardial infarction (MI) and at least one short-term safety outcome; data were extracted and risk of bias was judged with QUADAS-2.
Results:
From 2,743 records, 13 studies (10 cohorts, 3 trials; >80,000 participants) were included. hs-cTn 0/1-hour and 0/2-hour algorithms ruled out MI in roughly 40-60% of emergency-department patients, with rule-out sensitivity 98-100% and negative predictive value 99.0-99.9%. Among rule-out patients, 30-day MI or cardiac death was ≤1.0% (often 0.0-0.4%). Implementation trials showed shorter emergency-department stays (about 10.1 to 6.8 h) and higher direct discharge rates (50-71%) without significant 30-day major adverse cardiac events; performance was weaker in some high-risk subgroups, particularly those with known coronary artery disease.
Conclusions:
The hs-cTn-based accelerated diagnostic pathways provided very high sensitivity and negative predictive value for early exclusion of MI, with consistently low short-term event rates and improved emergency-department efficiency, but conservative application and local validation are advisable in high-risk populations and new healthcare settings.