Comparative analysis of dual and single marker strategies for rapid NSTEMI rule-out using cMyBP-C, Copeptin, and hs-cTnT in the emergency department

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Abstract Background This study compared the diagnostic and prognostic performance of various non-ST myocardial infarction (NSTEMI) rule-out-protocols, incorporating cardiac myosin-binding protein C (cMyBP-C), high-sensitivity cardiac troponin T (hs-cTnT), and Copeptin, both individually and as part of dual-marker strategies (DMS) against the European Society of Cardiology (ESC) 0/1h- and 0/3h-algorithms. Methods We enrolled 1,765 patients presenting to the emergency department (ED) with suspected NSTEMI. We evaluated biomarker algorithms including cMyBP-C (<10 ng/L, <2.3 ng/L), hs-cTnT (limit-of-blank [LoB, <3 ng/L], limit-of-detection [LoD, <5 ng/L], 99th percentile [≤14 ng/L]), and DMS combinations of Copeptin (<10 pmol/L) with hs-cTnT, cMyBP-C with hs-cTnT, and Copeptin with cMyBP-C. The ESC 0/1h and 0/3h algorithms were also tested. We calculated negative predictive values (NPVs) and sensitivities for NSTEMI rule-out and assessed effectiveness and prognostic performance based on cardiovascular events within 30 days and 1 year. Results The areas under the curve (AUC) were 0.922 for hs-cTnT, 0.917 for cMyBP-C, and 0.624 for Copeptin in diagnosing NSTEMI. DMS protocols showed NPVs of 99.1% to 100%, comparable to the ESC algorithms (99.3% to 100%). Sensitivities for DMS ranged from 96.2% to 100%. All protocols had low rates of the combined endpoint of cardiovascular events within 30 days (0.0% to 0.6%). Conclusions The ESC 0/1h-algorithm and DMS combining hs-cTnT with either cMyBP-C or Copeptin provide highly reliable and safe protocols for NSTEMI rule-out. These DMS approaches offer promising alternatives to current standards, potentially improving clinical decision-making and efficiency in EDs.Comparative ROC curves of biomarkersKaplan-Meier survival curves

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