Randomized Comparison of High-Sensitivity Troponin Reporting in Undifferentiated Chest Pain Assessment
Derek P Chew1, Christopher Zeitz2, Matthew Worthley2
1From the Flinders University, Adelaide, South Australia, Australia (D.P.C., H.G., C.A., S.Q., J.R., P.G.A.); Flinders Medical Centre, Adelaide, South Australia, Australia (D.P.C., P.G.A.); University of Adelaide, Adelaide, South Australia, Australia (C.Z., M.W., J.B.); The Royal Adelaide Hospital, Adelaide, South Australia, Australia (C.Z., M.W.); The Queen Elizabeth Hospital, Adelaide South Australia, Australia (J.B.); The Lyell McEwen Hospital, Adelaide, South Australia, Australia (M.A.); SA Pathology, SA Health Adelaide, South Australia, Australia (P.C.); Heart Foundation, South Australia, Australia (C.A.); and SA Health, Adelaide, Australia (M.H.). derek.chew@flinders.edu.au.
Background:
High-sensitivity troponin T (hs-TnT) assays promise greater discrimination of evolving myocardial infarction, but the impact of unguided implementation on the effectiveness of care is uncertain.
Methods And Results:
We evaluated the impact of hs-TnT reporting on care and outcome among chest pain patients presenting to 5 emergency departments within a multicenter randomized trial. Patients were allocated to hs-TnT reporting (hs-report) or standard reporting (std-report; Roche Elecys). The primary end point was death and new or recurrent acute coronary syndrome by 12 months. A total of 1937 patients without ST-segment elevation were enrolled between July 2011 and March 2013. The median age was 61 (interquartile range, 48-74) years, and 46.3% were women. During the index hospitalization, 1466 patients (75.7%) had maximal troponin <30 ng/L within 24 hours. Randomization to hs-report format did not alter the admission rate (hs-report: 57.7% versus std-report: 58.0%; P=0.069). There was no difference in angiography (hs-report: 11.9% versus std-report: 10.9%; P=0.479). The hs-reporting did not reduce 12-month death or new/recurrent acute coronary syndrome in the overall population (hs-report: 9.7% versus std-report: 7.2% [hazard ratio, 0.83 (0.57-1.22); P=0.362]). However, among those with troponin levels <30 ng/L, a modest reduction in the primary end point was observed (hs-report: 2.6% versus std-report: 4.4%, [hazard ratio, 0.58; 95% confidence interval, 0.34-0.1.00; P=0.050).
Conclusions:
High-sensitivity troponin reporting alone is associated with only modest changes in practice. Clinical effectiveness in the adoption of high-sensitivity troponin may require close coupling with protocols that guide interpretation and care.
Clinical Trial Registration:
URL: http://www.ANZCTR.org.au. Unique identifier: ACTRN12611000879965.
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