Rapid rule out for suspected myocardial infarction: is the algorithm appropriate for all?
Erez Marcusohn1, Danny Epstein2, Ariel Roguin3,4
1Department of Cardiology, Rambam Health Care Campus, HaAliya HaShniya St 8, Haifa, Israel, 3109601.
Insights
Patients with chest pain and low troponin levels (HsTnI < 5 ng/L) but moderate GRACE scores face higher risks of adverse cardiovascular events. Current guidelines may not sufficiently identify all high-risk individuals for early discharge.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Risk Stratification
Background:
- Patients with cardiac chest pain and low high-sensitive troponin I (HsTnI) levels (< 5 ng/L) generally have a favorable prognosis.
- European Society of Cardiology (ESC) guidelines suggest discharging patients with normal HsTnI, no chest pain, and a Global Registry of Acute Coronary Events (GRACE) score < 140 for outpatient evaluation.
- The current guideline-based approach may not adequately identify all patients at risk for adverse cardiovascular events.
Purpose of the Study:
- To evaluate the hypothesis that not all patients with a GRACE score < 140 and undetectable HsTnI should be discharged for ambulatory testing.
- To assess the risk of major adverse cardiovascular events (MACE) in patients with chest pain, low HsTnI, and varying GRACE scores.
- To refine risk stratification protocols for patients presenting with chest pain in the emergency department.
Main Methods:
- A population-based retrospective cohort study was conducted at a large tertiary care center.
- Included patients were discharged between February 2016 and February 2019 after a rule-out myocardial infarction (MI) protocol.
- Data analysis focused on HsTnI levels, GRACE risk scores, and subsequent adverse events, including death, revascularization, and readmission for acute coronary syndrome (ACS).
Main Results:
- Of 13,800 patients discharged after MI rule-out, 9,236 (67%) had HsTnI < 5 ng/L.
- Among those with HsTnI < 5 ng/L, 7,705 patients met criteria for low (n=7,162) or moderate (n=543) GRACE risk scores.
- Moderate-risk patients (GRACE score < 140) experienced significantly higher rates of adverse events (4.6% vs. 2.1%, P < 0.001), including death (0.5% vs. 0.1%), revascularization (3.9% vs. 1.8%), and ACS readmission (1.1% vs. 0.4%).
Conclusions:
- Patients with chest pain, HsTnI < 5 ng/L, and GRACE score < 140 have a 2-4% risk of adverse events within 60 days.
- The observed differences in adverse events suggest that rapid rule-out algorithms should be reserved for low-risk patients with a GRACE score < 73.
- Current risk stratification may need refinement to better identify patients who can be safely discharged for outpatient workup.
Aims:
Patients presenting to the emergency department (ED) with cardiac chest pain and high-sensitive troponin I (HsTnI) less than 5 ng/L have very good prognosis and low risk for major adverse cardiovascular events. The 2015 European Society of Cardiology (ESC) guidelines for non-ST-elevation myocardial infarction (MI)/acute coronary syndrome (ACS) suggests that patients with normal high-sensitive troponin, which are free of chest pain and have a global registry of acute coronary events (GRACE) score less than 140 are eligible for discharge from the hospital for outpatient workup. Our hypothesis suggests that not all patients with GRACE score under 140 should be discharged for ambulatory tests even with undetectable HsTnI as recommended in the guidelines.
Methods And Results:
Population-based retrospective cohort study in a large tertiary care centre. The study population included all patients discharged from the hospital between 1 February 2016 and 28 February 2019 following rule out of MI. During the study period, a total of 13 800 patients were discharged from the hospital after rule out of MI. Among them, 9236 (67%) had HsTnI below 5 ng/L. A total of 7705 patients (83%) met the criteria for low (n = 7162) or moderate (n = 543) GRACE risk score. Moderate-risk patients had significantly more adverse events than low-risk patients (4.6% vs. 2.1%, P < 0.001). They are in higher risk of death (0.5% vs. 0.1%, P = 0.042), revascularization (3.9% vs. 1.8%, P = 0.0047), and readmission due to ACS (1.1% vs. 0.4%, P = 0.031).
Conclusion:
Patients presenting to the ED with chest pain and HsTnI less than 5 ng/L and GRACE score under 140 have 2-4% adverse event in 60 days. The differences between the groups suggest using rapid rule out algorithms for only low-risk patients with GRACE score under 73.
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