Great debate: a dual biomarker strategy improves the triage of patients with suspected acute coronary syndrome

Suspected myocardial infarction in patients with acute chest pain at rest is one of the most common diagnostic categories leading to emergency hospital admission and emergency department overcrowding worldwide. Efforts are being made to improve the efficiency of currently used triage and diagnostic work-up strategies. Despite major advances in recent years with the use of high-sensitivity cardiac troponin, challenges still exist regarding how to accurately and rapidly rule out or rule in myocardial infarction, as current strategies are relatively slow due to the need for serial troponin measurements. The 2023 European Society of Cardiology (ESC) guidelines recommend a 0 h/1 h or a 0 h/2 h high-sensitivity troponin diagnostic algorithm, instead of the previously suggested 0 h/3 h diagnostic protocol, to reduce the time required to discharge patients with suspected acute coronary syndrome/myocardial infarction. The ESC endorsed algorithms are not without difficulty, and alternative ways of improving triaging have been proposed, particularly a dual biomarker rule-out strategy involving the combined measurement of copeptin and troponin. Supporters of the dual biomarker strategy argue that a timely optimized algorithm can potentially allow the safe rule-out of myocardial infarction earlier than currently used strategies. In the present Great Debate article, two expert teams discuss the 'pros' and 'cons' of implementing single vs dual biomarker strategies for the rule-in and rule-out of myocardial infarction, under the moot topic 'A dual biomarker strategy improves the triage of patients with suspected acute coronary syndrome'. They address in detail many of the controversial issues currently affecting everyday clinical practice and provide insightful comments on how to best triage patients presenting with suspected acute myocardial infarction.