Diagnostic accuracy of point-of-care high-sensitivity troponin algorithms for emergency department rule-out and rule-in of acute myocardial infarction: a systematic review and meta-analysis

PURPOSE: To evaluate the diagnostic accuracy of high-sensitivity point-of-care (hs-POC) cardiac troponin algorithms for rule-out and rule-in of acute myocardial infarction (AMI) in emergency departments. METHODS: This PROSPERO-registered systematic review (CRD420251170970) searched MEDLINE, CENTRAL and trial registries (2005-2025) for studies evaluating serial hs-POC troponin testing (0 hour/1 hour or 0 hour/2 hour algorithms) in adults with suspected AMI. Primary outcomes were sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. RESULTS: Eight studies (19 datasets; 9384 patients; 1157 AMI cases) evaluated four hs-POC platforms: Siemens Atellica VTLi, PHC Pathfast, QuidelOrtho TriageTrue and BioMérieux SPINCHIP. Rule-out algorithms achieved pooled sensitivity 98.0% (95% CI 96.0% to 99.0%) and NPV 99.9% at an assumed AMI prevalence of 10%, with no additional missed AMI events reported during follow-up among patients classified as rule-out. Rule-in algorithms achieved specificity 96.0% (94.0% to 97.0%) and PPV 68.5% assuming a disease prevalence of 10%. Complex multiparametric algorithms showed higher pooled sensitivity (99.3%, I²=0%) than simple cut-off approaches (96.9%). The 0 hour/1 hour protocol showed similar diagnostic accuracy to 0 hour/2 hour while potentially allowing clinical decisions approximately 1 hour earlier. All four evaluated platforms achieved rule-out sensitivities ≥97%. All evaluated platforms met contemporary high-sensitivity analytical criteria and reported turnaround times of 8-17 min enabling rapid clinical decision-making and high diagnostic accuracy for both rule-out and rule-in applications. Overall risk of bias was low in 75% of datasets. CONCLUSIONS: hs-POC troponin algorithms demonstrated high diagnostic accuracy for both rule-out and rule-in of AMI. Validated serial testing pathways, including 0 hour/1 hour and 0 hour/2 hour strategies, showed favourable diagnostic performance across evaluated platforms. Further implementation studies are needed to define their impact on emergency department workflow and patient outcomes. PROSPERO REGISTRATION NUMBER: CRD420251170970.