Optimising the early rule-out and rule-in of myocardial infarction using biomarkers

Detailed clinical assessment, the electrocardiogram and cardiac troponin form the three cornerstones of the early diagnosis of myocardial infarction (MI). After the clinical introduction of high-sensitivity cardiac troponin (hs-cTn) assays about 8 years ago, precise quantification of cardiomyocyte injury around the 99th percentile became possible and thereby substantially increased the accuracy of MI diagnosis from blood drawn at presentation to the emergency department. Higher diagnostic accuracy enabled the development and validation of multiple early hs-cTn-based diagnostic algorithms including the ESC 0/ 1-hour algorithm, which substantially reduced the time required for safe rule-out or rule-in of MI. This algorithm is widely applicable, including in patients with renal dysfunction and in the USA, where hs-cTn approval is slightly different from the rest of the world. Apart from hs-cTn, other emerging cardiac biomarkers might have the potential to further improve the early triage of patients with suspected MI.