Echocardiographic evaluation of LV diastolic function made simple by ASE😍

How the ESC 0 h/1 h Troponin Algorithm Speeds Up the Diagnosis of Myocardial Infarction Every minute matters when a patient arrives in the emergency department with suspected myocardial infarction (MI). The challenge is identifying who can be safely discharged, who requires further observation, and who needs immediate treatment. The European Society of Cardiology (ESC) 0 h/1 h algorithm uses high-sensitivity cardiac troponin (hs-cTn) together with clinical assessment and the ECG to rapidly guide these decisions. Step 1: Initial assessment - Every patient should undergo: - Clinical assessment and vital signs. - A 12-lead ECG. - Blood sampling for hs-cTn at presentation (0 h). Patients with shock, those requiring cardiopulmonary resuscitation (CPR), or persistent ST-segment elevation are not managed with the 0 h/1 h algorithm. These patients are considered high risk and require immediate rule-in and urgent reperfusion management. Step 2: The first troponin result After the first blood sample is collected, the laboratory processes the specimen. The turnaround time is the interval from blood collection until the result becomes available to the treating clinician. Using an automated laboratory platform, this is typically about 1 hour. This period includes: Transport of the blood sample to the laboratory. ◼️Sample registration. ◼️Centrifugation. ◼️Analysis on the automated platform. ◼️Reporting of the result into the electronic medical record. This means that although blood is drawn at 0 h, the earliest clinical decision based on that sample is generally made at 1 h. Step 3: Rule-out pathway NSTEMI can be ruled out if: ⬜ The initial hs-cTn concentration is very low, provided chest pain began more than 3 hours earlier. ⬜ Or the baseline hs-cTn is low with no significant increase after 1 hour. These patients have an extremely low risk of acute myocardial infarction. Management includes: ◻️ Considering alternative causes of chest pain. ◻️ Possible outpatient follow-up when clinically appropriate. The estimated risk is very low: 🔻Myocardial infarction during the index visit: <0.3% 🔻30-day major adverse cardiovascular events (MACE): <0.5% Step 4: Rule-in pathway Patients are classified as rule-in if: - The initial hs-cTn concentration is high. - Or there is a significant rise in hs-cTn within the first hour. The exact troponin thresholds and required changes are assay-specific. These patients have a high likelihood of acute myocardial infarction and should receive: - Hospital admission. - Continuous cardiac monitoring. - Early coronary angiography. - Guideline-directed treatment. The estimated risk is high: ◻️ Myocardial infarction during the index visit: >65% ◻️ 30-day MACE: >70% Step 5: The observation zone Not every patient fits neatly into rule-out or rule-in. Patients with intermediate results enter the observation zone. Further evaluation includes: - Repeat hs-cTn testing at 3 hours. - Echocardiography when indicated. - Continued clinical assessment. If there is no significant 3-hour change, clinicians should consider alternative diagnoses and determine disposition based on the overall clinical picture. If a significant 3-hour change is detected, the patient should be managed as a rule-in case. A practical point about timing The times in the algorithm refer to when blood is drawn, not when results become available. For example: - Blood drawn at 0 h is usually reported at 1 h. - Blood drawn at 1 h is usually reported at 2 h. - Blood drawn at 3 h is usually reported at 4 h. Therefore, local laboratory turnaround time determines the earliest moment a clinical decision can be made. Reference: Collet JP, Thiele H, Barbato E, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European Heart Journal. 2020.