Single high-sensitivity troponin levels to assess patients with potential acute coronary syndromes

Abstract

ObjectiveWe tested the hypothesis that patients with a potential acute coronary syndrome (ACS) and very low levels of high-sensitivity cardiac troponin I can be efficiently and safely discharged from the emergency department after a single troponin measurement.MethodsThis prospective cohort study recruited 2255 consecutive patients aged ≥18 years presenting to the Emergency Department, Royal Perth Hospital, Western Australia, with chest pain without high-risk features but requiring the exclusion of ACS. Patients were managed using a guideline-recommended pathway or our novel Single Troponin Accelerated Triage (STAT) pathway. The primary outcome was the percentage of patients discharged in <3 hours. Secondary outcomes included the duration of observation and death or acute myocardial infarction in the next 30 days.ResultsThe study enrolled 1131 patients to the standard cohort and 1124 to the STAT cohort. Thirty-eight per cent of the standard cohort were discharged directly from emergency department compared with 63% of the STAT cohort (p<0.001). The median duration of observation was 4.3 (IQR 3.3–7.1) hours in the standard cohort and 3.6 (2.6–5.4) hours in the STAT cohort (p<0.001), with 21% and 38% discharged in <3 hours, respectively (p<0.001). No patients discharged directly from the emergency department died or suffered an acute myocardial infarction within 30 days in either cohort.ConclusionsAmong low-risk patients with a potential ACS, a pathway which incorporates early discharge based on a single very low level of high-sensitivity cardiac troponin increases the proportion of patients discharged directly from the emergency department, reduces length of stay and is safe.Trial registration numberACTRN12618000797279.

Early discharging patients with chest pain using EDACS-ADP and COMPASS-MI risk predictors

“…One of the significant sensitive biomarkers for acute myocardial infarction (AMI) is high-sensitivity cardiac Troponin I (hsTnI), frequently used in the routine of chest pain in the emergency department, is used alone or in conjunction with scoring systems, especially in deciding the discharge of patients with low and medium risk chest pain. High precision and sensitivity of the biomarker allow physicians to rule-out AMI and serial troponin measurements to ensure discharge of the patients with low risk [7]. Very low first troponin levels are predictors of very low 30-day MACE and death [7][8][9].…”

“…High precision and sensitivity of the biomarker allow physicians to rule-out AMI and serial troponin measurements to ensure discharge of the patients with low risk [7]. Very low first troponin levels are predictors of very low 30-day MACE and death [7][8][9]. There is a need for serial troponin testing for patients with chest pain less than 2 h due to the low NPV values of hsTnI < 5 ng/L [7,8].…”

“…Very low first troponin levels are predictors of very low 30-day MACE and death [7][8][9]. There is a need for serial troponin testing for patients with chest pain less than 2 h due to the low NPV values of hsTnI < 5 ng/L [7,8]. These patients are still in debate for discharging from emergency departments.…”

“…Besides the studies carried out to decide on the early discharge of patients with chest pain via 0-h, 1-h, and 2-h high-sensitive Troponin (hsTn) [7], Emergency Department Assessment of Chest Pain and Accelerated Diagnostic Protocol (EDACS-ADP) have been put forward to determine the follow-up needs of patients with low-risk chest pain both with the aid of risk factors and biomarkers [10].…”