A-026 Impact of Chronic Kidney Disease on the Diagnostic Performance of the 0/1-Hour High-Sensitivity Cardiac Troponin T Triage Algorithm

Abstract

The 0/1-hour triage algorithm using high-sensitivity cardiac troponin (hs-cTn) is recommended for rapid rule-out and rule-in of myocardial infarction (MI). However, its performance in patients with chronic kidney disease (CKD), who often have chronically elevated troponin remains less certain in US populations. Our goal is to evaluate the safety and efficacy of the ESC 0/1-hour hs-cTnT algorithm across different stages of kidney function in a multicenter US cohort. This is a secondary analysis of a prospective multicenter cohort study (STOP CP). Adult patients with symptoms of acute coronary syndrome and no ST-segment elevation on initial electrocardiogram accrued from 8 US EDs. Baseline and 1-hour hs-cTnT levels were measured (Roche Diagnostics). NSTEMI and MACE (cardiac death, myocardial infarction, and coronary revascularization) at 30 days were adjudicated. Patients were stratified into CKD (eGFR <60 ml/min/1.73 m2) and non-CKD (eGFR =60 ml/min/1.73 m2) groups. Diagnostic performance of sensitivity, specificity, positive and negative predictive values of ESC 0/1-hour hs-cTnT algorithm were assessed in these groups. Statistical analysis was performed using SAS statistical software and R program, and p values <0.05 are considered significant. Among 1461 patients included in the study, 784 (58%) were male, 837 (57%) white and the mean age was 58 years. CKD was present in 282 patients (19%). Clinically adjudicated NSTEMI prevalence was 21% in CKD group versus 7.5% in non-CKD group. The 0/1-hour algorithm classified only 12 of 282 CKD patients (4.3%) to the rule-out zone (<6 ng/L) compared to 468 of 1179 non-CKD patients (39.7%, p <0.001). However, sensitivity and NPV of rule-out was >99% for both CKD and non-CKD groups. In CKD group, most patients fell into indeterminate/observe (62.4%) and rule-in zones (33.3%), compared with 55.0% and 5.3% in non-CKD group. Rule-in specificity of CKD (38 of 94) was much lower compared to non-CKD (53 of 62). With the increase in severity of CKD, percentage of patients in ruled-in zone increased with significant improvement in specificity (p <0.001). Still, overall efficacy (total of true rule-in and true rule-out) of CKD group was much lower in than non-CKD group. To address these limitations, we are now evaluating new eGFR-adjusted triage algorithms to rapidly refine rule-out and rule-in classification in CKD. In this large multicenter US cohort, ESC 0/1-hour hs-cTnT algorithm significantly underperformed in CKD patients, with low rule-out rate and high false-positive classifications driven by non-specific hs-cTnT elevation. These findings highlight the limitations of current rapid triage algorithms in CKD populations and underscore the urgent need for renal function integrated approaches to improve rapid triage accuracy and patient safety.