BACKGROUND: Few studies have comprehensively examined high-sensitivity cardiac troponin I (hs-cTnI) based diagnostic pathways for myocardial infarction (MI) in early presenters using a Siemens ADVIA Centaur hs-cTnI assay. METHODS: We conducted a prospective multicenter cohort study in Emergency Departments involving 414 patients suspected of MI within 6 h of symptom onset. We evaluated three hs-cTnI-based pathways (High-STEACS, ESC 0/1-h, 0/2-h)
and four pathways incorporating medical history and physical findings (ADAPT, EDACS, HEART, GRACE). We evaluated negative predictive value (NPV) and sensitivity as safety measures, and percentage ruled out as an efficiency measure for a primary outcome of type 1 myocardial infarction or cardiac death within 30 days. RESULTS: Median age was 72 years (interquartile range 58-82), and 30.4 % (126/414) of patients were over 80. Females comprised 44.2 % (183/414) of patients, 87.7 % (363/414) had chest pain, and the primary outcome occurred in 9.2 % (38/414). The High-STEACS pathway ruled out 62.0 % of patients without missing a case of an MI. The ESC 0/1-h and 0/2-h pathways showed high NPV and sensitivities
however, they ruled out fewer patients (35.9 % and 45.2 %, respectively). The ADAPT, EDACS, and HEART pathways demonstrated high NPV and sensitivities but ruled out fewer patients (15-27 %). The GRACE pathway missed 2 cases with primary clinical outcomes. Among patients over 80 without MI, initial hs-cTnI concentration was ≥ 3 ng/L in 99.1 % and ≥ 5 ng/L in 84.1 %. CONCLUSIONS: The High-STEACS pathway was the most efficient among the hs-cTnI-based pathways while maintaining excellent safety performance in early presenters.