Implementation of an early rule-out pathway for myocardial infarction using a high-sensitivity cardiac troponin T
Dennis Sandeman1, Maaz B J Syed2, Dorien M Kimenai3
1Cardiology Department, NHS Fife, Kirkcaldy, UK.
Insights
Implementing an early rule-out pathway for acute coronary syndrome using high-sensitivity cardiac troponin T (hs-cTnT) <5 ng/L at presentation safely reduced hospital stays. This strategy allows for early discharge without compromising patient safety over one year.
Area of Science:
- Cardiology
- Emergency Medicine
- Biomarker Research
Background:
- Acute coronary syndrome (ACS) diagnosis relies on clinical assessment and cardiac biomarkers.
- High-sensitivity cardiac troponin (hs-cTn) assays improve early detection of myocardial injury.
- Current protocols for ruling out ACS can lead to prolonged hospital stays.
Purpose of the Study:
- To evaluate the safety and efficacy of an early rule-out pathway for suspected ACS.
- To determine if a lower hs-cTnT threshold (<5 ng/L) facilitates safe early discharge.
- To assess the impact on hospital duration of stay and 1-year all-cause mortality.
Main Methods:
- Prospective single-centre cohort study comparing standard care with an early rule-out pathway.
- Intervention group: rule-out if hs-cTnT <5 ng/L at presentation (symptoms ≥3h) or unchanged at 3h.
- Standard care: rule-out if hs-cTnT <14 ng/L at presentation and 6-12h; compared duration of stay and 1-year mortality.
Main Results:
- 10,315 patients included; 6642 (standard care) and 3673 (intervention).
- Duration of stay significantly reduced from 534 min (IQR, 220-2279) to 390 min (IQR, 218-1910) (p<0.001).
- 1-year all-cause death rates were similar: 10.9% (standard care) vs. 10.4% (intervention) (aOR 1.02, 95% CI 0.88-1.18).
Conclusions:
- Implementing an early rule-out pathway using hs-cTnT <5 ng/L is effective in reducing hospital stay duration for suspected ACS.
- This strategy demonstrates safety, with no significant increase in 1-year all-cause mortality.
- The findings support the safe early discharge of low-risk patients with suspected ACS.
Objectives:
Patients with suspected acute coronary syndrome and high-sensitivity cardiac troponin (hs-cTn) concentrations below the limit of detection at presentation are low risk. We aim to determine whether implementing this approach facilitates the safe early discharge of patients.
Methods:
In a prospective single-centre cohort study, consecutive patients with suspected acute coronary syndrome were included before (standard care) and after (intervention) implementation of an early rule-out pathway. During standard care, myocardial infarction was ruled out if hs-cTnT concentrations were <99th centile (14 ng/L) at presentation and at 6-12 hours after symptom onset. In the intervention, patients were ruled out if hs-cTnT concentrations were <5 ng/L at presentation and symptoms present for ≥3 hours or were ≥5 ng/L and unchanged within the reference range at 3 hours. We compared duration of stay (efficacy) and all-cause death at 1 year (safety) before and after implementation.
Results:
We included 10 315 consecutive patients (64±16 years, 46% women) with 6642 (64%) and 3673 (36%) in the standard care and intervention groups, respectively. Duration of stay was reduced from 534 (IQR, 220-2279) to 390 (IQR, 218-1910) min (p<0.001) after implementation. At 1 year, all-cause death occurred in 10.9% (721 of 6642) and 10.4% (381 of 3673) of patients in the standard care group (referent) and intervention group, respectively (adjusted OR 1.02, 95% CI 0.88 to 1.18).
Conclusion:
In patients with suspected acute coronary syndrome, implementing an early rule-out pathway using hs-cTnT concentrations <5 ng/L at presentation reduced the duration of stay in hospital without compromising safety.
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