Single high-sensitivity troponin levels to assess patients with potential acute coronary syndromes
Cara Barnes1, Daniel M Fatovich2,3,4, Stephen P J Macdonald2,3,4
1Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia.
Insights
A new pathway using a single troponin test allows safe and efficient early discharge for low-risk acute coronary syndrome patients from the emergency department, reducing observation times.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Pathways
Background:
- Acute coronary syndrome (ACS) diagnosis requires careful evaluation in the emergency department.
- Current protocols may lead to prolonged observation periods for patients with chest pain.
- Efficient and safe discharge strategies are crucial for emergency department flow.
Purpose of the Study:
- To evaluate the efficacy and safety of a novel Single Troponin Accelerated Triage (STAT) pathway.
- To determine if a single high-sensitivity cardiac troponin I measurement can facilitate early discharge for low-risk ACS patients.
- To compare the STAT pathway with standard care regarding discharge rates and observation duration.
Main Methods:
- A prospective cohort study involving 2255 patients presenting with chest pain.
- Comparison of a standard care pathway with the novel STAT pathway.
- Primary outcome: percentage of patients discharged within 3 hours; secondary outcomes: observation duration, 30-day major adverse cardiac events.
Main Results:
- The STAT pathway discharged 63% of patients within 3 hours, compared to 38% in the standard cohort (p<0.001).
- Median observation time was reduced with the STAT pathway (3.6 hours vs. 4.3 hours, p<0.001).
- No deaths or acute myocardial infarctions occurred within 30 days for directly discharged patients in either group.
Conclusions:
- The STAT pathway significantly increases direct emergency department discharges for low-risk ACS patients.
- This accelerated triage strategy safely reduces patient observation length of stay.
- Early discharge based on a single troponin measurement is efficient and safe for selected patients.
Objective:
We 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.
Methods:
This 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.
Results:
The 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.
Conclusions:
Among 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 Number:
ACTRN12618000797279.
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