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0h/1h Rule-out Application — EECC MCQ

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EasyCoronary Artery Disease0h/1h Rule-out ApplicationEECC

A 70-year-old man with ACS has a troponin measured using a high-sensitivity assay. His 0h troponin is 3 ng/L (99th percentile 14 ng/L) and 1h troponin is 4 ng/L (delta 1 ng/L). According to the ESC 0h/1h algorithm, what is the classification?

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Correct answer: A — Rule-out — very low 0h value (<5 ng/L for hs-cTnI Abbott) AND low 1h delta (<2 ng/L) safely excludes MI with a negative predictive value >99%; the patient can be considered for early discharge after clinical assessment

The ESC 0h/1h rapid rule-out/rule-in algorithm for NSTEMI (assay-specific thresholds for hs-cTnI Abbott): Rule-out = 0h <5 ng/L AND 1h delta <2 ng/L → NPV >99% for MI, safe for discharge with appropriate safety-netting. Rule-in = 0h ≥52 ng/L OR 1h delta ≥6 ng/L. Observe zone = neither criteria met → serial sampling at 3h. This patient (0h=3, delta=1) meets RULE-OUT criteria. The 2023 ESC ACS Guidelines recommend this algorithm (Class I, LOE B) with assay-specific cut-offs. Approximately 60% of patients are rapidly ruled out, 15% ruled in, and 25% require observation. Important: rule-out applies to MI only — alternative diagnoses (PE, aortic dissection, myocarditis) must be considered clinically. Patients should receive appropriate safety-netting advice before discharge.

Reference: ESC (2023): ACS Guidelines