ESC vs. High-STEACS: Choosing the Right hs-cTn Strategy for Your Emergency Department

Rapid NSTEMI Diagnosis in the ED: What the Latest Evidence Says About ESC 0/1‑Hour vs. High‑STEACS Pathways

When patients arrive in the Emergency Department with acute chest discomfort—excluding STEMI—the ability to rapidly and safely diagnose NSTEMI is essential. High‑sensitivity cardiac troponin (hs‑cTn) assays have transformed this process, and two accelerated diagnostic pathways dominate current practice: the ESC 0/1‑hour algorithm and the High‑STEACS 0/2‑ or 0/3‑hour pathways. A recent prospective study in JACC provides valuable clarity on how these strategies compare, confirming strong performance for both while highlighting meaningful differences that matter for real‑world implementation.

ESC 0/1‑Hour Algorithm: Higher Sensitivity With Troponin I

For centers using hs‑troponin I assays, the ESC 0/1‑hour algorithm demonstrated superior sensitivity for detecting NSTEMI. This heightened sensitivity reduces the risk of false negatives—an important consideration for institutions prioritizing diagnostic certainty or facing medico‑legal pressures.

Trade‑off: Higher sensitivity comes at the cost of fewer rapid rule‑outs, which can slow ED throughput and increase length of stay.

High‑STEACS Pathways: Greater Efficiency With Troponin I

High‑STEACS, especially when paired with hs‑troponin I, offers a higher proportion of early rule‑outs. This can meaningfully improve patient flow, reduce crowding, and support departments under economic or staffing constraints.

Trade‑off: Sensitivity is slightly lower than the ESC algorithm when using troponin I, though still within a safe and guideline‑supported range.

When Using Troponin T, the Differences Narrow

For institutions using hs‑troponin T assays, the performance gap between ESC and High‑STEACS largely disappears. Both pathways deliver comparable safety and diagnostic accuracy, making the choice more about workflow preference than clinical performance.

Choosing the Right Pathway for Your ED

The optimal strategy depends on local priorities:

• If diagnostic certainty is paramount (especially with troponin I): The ESC 0/1‑hour algorithm may be preferred for its higher sensitivity.

• If ED efficiency and rapid rule‑out capacity are critical: High‑STEACS offers strong performance with better throughput.

Both pathways are validated, guideline‑supported, and safe when implemented correctly. Tailoring the approach to institutional needs is not only reasonable—it’s optimal.

Take‑Home Point

Both the ESC 0/1‑hour and High‑STEACS pathways are excellent tools for NSTEMI evaluation. Their relative advantages depend on the troponin assay used and the operational priorities of the emergency department, balancing sensitivity against efficiency.