Outcomes in Patients With Chest Pain Discharged After Evaluation Using a High-Sensitivity Troponin T Assay
Atosa Nejatian1, Åsa Omstedt2, Jonas Höijer3
1Functional Area of Emergency Medicine, Karolinska University Hospital Solna, Stockholm, Sweden; Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.
Insights
The introduction of high-sensitivity troponin T (hsTnT) assays in emergency departments reduced major adverse cardiac events (MACEs) for directly discharged patients. However, it identified more at-risk patients among those admitted, improving overall evaluation.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Diagnostics
Background:
- Unspecified chest pain is a common emergency department diagnosis.
- The prognostic impact of high-sensitivity troponin T (hsTnT) assays in this population is unclear.
Purpose of the Study:
- To evaluate if hsTnT assay implementation reduces major adverse cardiac events (MACEs) and improves cardiovascular (CV) risk profiling in chest pain patients discharged from the emergency department (ED).
Main Methods:
- A retrospective study of 65,696 patients with unspecified chest pain discharged from 16 Swedish EDs (2006-2013).
- Comparison of outcomes between patients evaluated with conventional assays versus hsTnT assays.
- Analysis of 30-day MACE and CV risk profiles using national registry data.
- Separate analysis for directly discharged patients and those admitted after initial evaluation.
Main Results:
- Directly discharged patients evaluated with hsTnT had fewer MACEs (0.6% vs. 0.9%) and a lower CV risk profile.
- Patients discharged after admission had more MACEs (7.2% vs. 3.4%) with hsTnT, indicating identification of higher-risk individuals.
- hsTnT assay implementation was associated with differential outcomes based on admission status.
Conclusions:
- hsTnT assays improve risk stratification for chest pain patients in the ED.
- Directly discharged patients benefit from hsTnT evaluation with reduced MACEs.
- The assay aids in identifying true at-risk patients, leading to better management and improved ED evaluations.
Background:
Most patients with chest pain are discharged from the emergency department (ED) with the diagnosis "unspecified chest pain." It is unknown if evaluation with a high-sensitivity troponin T (hsTnT) assay affects prognosis in this large population.
Objectives:
The aim was to investigate whether the introduction of an hsTnT assay is associated with reduced incidence of major adverse cardiac events (MACEs) and cardiovascular (CV) risk profile in patients with chest pain discharged from the ED.
Methods:
The study included 65,696 patients with "unspecified chest pain" discharged from 16 Swedish hospital EDs between 2006 and 2013 in which an hsTnT assay was introduced as the clinical routine. Patients evaluated with a conventional and an hsTnT assay were compared regarding the occurrence of 30-day MACE and CV risk profile based on information from national registries. Patients directly discharged and those discharged after an initial admission were analyzed separately.
Results:
Fewer directly discharged patients experienced a MACE when evaluated with an hsTnT compared with a conventional assay (0.6% vs. 0.9%; odds ratio [OR]: 0.7; 95% confidence interval [CI]: 0.57 to 0.83). In contrast, more patients discharged after an initial admission experienced a MACE when evaluated with an hsTnT (7.2% vs. 3.4%; OR: 2.18; 95% CI: 1.76 to 2.72). Admitted patients had a higher general CV risk profile when evaluated with hsTnT, whereas directly discharged patients had a lower general CV risk profile with the same test.
Conclusions:
Patients directly discharged from the ED with unspecified chest pain experienced fewer MACEs and had a better risk profile when evaluated with hsTnT. Our findings suggest that more true at-risk patients were identified and admitted. The implementation of hsTnT assays in Swedish hospitals has improved evaluations in the ED.
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