A single centre prospective cohort study addressing the effect of a rule-in/rule-out troponin algorithm on routine
Jack Marjot1, Thomas E Kaier1, Katherine Henderson2
11 King's College London BHF Centre, St Thomas' Hospital, London, UK.
Insights
Implementing a rapid diagnostic algorithm for acute coronary syndromes using high-sensitivity troponin assays allows for quick patient triage. This strategy effectively rules out or in myocardial injury, improving emergency department workflows.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Diagnostics
Background:
- New European Society of Cardiology guidelines (2015) recommend high-sensitivity troponin assays for diagnosing acute coronary syndromes without ST-segment elevation.
- These guidelines utilize a '0 hour' blood test for rapid 'rule-in' and 'rule-out' of acute myocardial injury.
- While validated in studies, the real-world impact of implementing these algorithms in clinical practice remains largely undescribed.
Purpose of the Study:
- To describe the impact of implementing a high-sensitivity troponin rapid diagnostic algorithm on patient journeys in an inner-city Emergency Department.
- To evaluate the effectiveness of the algorithm in routine clinical practice.
Main Methods:
- Prospective data collection from electronic records at a large Central London hospital over seven months.
- Analysis of high-sensitivity troponin T measurements and algorithm application before, during, and after implementation.
- Tracking of patient triage and repeat testing patterns.
Main Results:
- Over 213 days, 4644 patients underwent high-sensitivity troponin T testing.
- 40.4% of patients were 'ruled-out' and 7.6% were 'ruled-in' at presentation.
- A 37.5% increase in repeat high-sensitivity troponin T measurements within 1.5 hours was observed for 'intermediate risk' patients.
Conclusions:
- The introduction of a 0-hour 'rule-in'/'rule-out' algorithm facilitates rapid triage for 48% of patients.
- The algorithm is associated with expedited repeat testing for patients categorized as intermediate risk.
- Implementation in routine practice streamlines the diagnostic pathway for acute myocardial injury.
Aims:
In 2015, the European Society of Cardiology introduced new guidelines for the diagnosis of acute coronary syndromes in patients presenting without persistent ST-segment elevation. These guidelines included the use of high-sensitivity troponin assays for 'rule-in' and 'rule-out' of acute myocardial injury at presentation (using a '0 hour' blood test). Whilst these algorithms have been extensively validated in prospective diagnostic studies, the outcome of their implementation in routine clinical practice has not been described. The present study describes the change in the patient journey resulting from implementation of such an algorithm in a busy innercity Emergency Department.
Methods And Results:
Data were prospectively collected from electronic records at a large Central London hospital over seven months spanning the periods before, during and after the introduction of a new high-sensitivity troponin rapid diagnostic algorithm modelled on the European Society of Cardiology guideline. Over 213 days, 4644 patients had high-sensitivity troponin T measured in the Emergency Department. Of these patients, 40.4% could be 'ruled-out' based on the high-sensitivity troponin T concentration at presentation, whilst 7.6% could be 'ruled-in'. Adoption of the algorithm into clinical practice was associated with a 37.5% increase of repeat high-sensitivity troponin T measurements within 1.5 h for those patients classified as 'intermediate risk' on presentation.
Conclusions:
Introduction of a 0 hour 'rule-in' and 'rule-out' algorithm in routine clinical practice enables rapid triage of 48% of patients, and is associated with more rapid repeat testing in intermediate risk patients.
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