Rapid Acute Coronary Syndrome Evaluation Over One Hour With High-Sensitivity Cardiac Troponin I: A United
Joseph Miller1, Bernard Cook1, Chaun Gandolfo2
1Henry Ford Hospital, Detroit, MI.
Insights
A 0/1-hour accelerated protocol using high-sensitivity cardiac troponin (hs-cTn) did not increase safe emergency department discharges for myocardial infarction (MI) compared to standard care. This study found no significant difference in 30-day outcomes between the two protocols.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Trials
Background:
- Evaluating patients for myocardial infarction (MI) in emergency departments (EDs) often involves lengthy troponin testing protocols.
- Accelerated protocols using high-sensitivity cardiac troponin (hs-cTn) aim to expedite MI rule-out and patient discharge.
- The real-world effectiveness of a 0/1-hour accelerated hs-cTn protocol in the US compared to standard care is not well-established.
Purpose of the Study:
- To compare the effectiveness and safety of a 0/1-hour accelerated hs-cTn protocol versus a 0/3-hour standard care protocol for MI evaluation.
- To determine if the accelerated protocol leads to a higher proportion of safe emergency department discharges.
- To assess 30-day rates of death or MI in patients managed under both protocols.
Main Methods:
- A stepped-wedge, randomized trial (RACE-IT) involving 32,609 patients across 9 US emergency departments.
- Patients with suspected MI underwent hs-cTn I testing; those with concentrations at or below the 99th percentile were eligible.
- Comparison between a 0/1-hour accelerated protocol and a 0/3-hour standard care protocol (modified HEART score used in standard care).
Main Results:
- No significant difference in safe ED discharges was observed between the accelerated (57.8%) and standard care (59.5%) protocols (aOR=1.05, 95% CI 0.95 to 1.16).
- The incidence of 30-day death or MI was similar in both groups: 0.4% in the standard care group and 0.4% in the accelerated protocol group (aOR=0.84, 95% CI 0.43 to 1.68).
- A total of 19,152 patients (58.7%) were discharged directly from the ED across both protocols.
Conclusions:
- The 0/1-hour accelerated protocol using hs-cTn I did not result in more safe ED discharges compared to standard care.
- The accelerated protocol did not increase the risk of 30-day death or MI.
- Current accelerated hs-cTn protocols may not offer a significant advantage in terms of safe discharge rates in real-world US emergency department settings.
Study Objective:
The real-world effectiveness and safety of a 0/1-hour accelerated protocol using high-sensitivity cardiac troponin (hs-cTn) to exclude myocardial infarction (MI) compared to routine care in the United States is uncertain. The objective was to compare a 0/1-hour accelerated protocol for evaluation of MI to a 0/3-hour standard care protocol.
Methods:
The RACE-IT trial was a stepped-wedge, randomized trial across 9 emergency departments (EDs) that enrolled 32,609 patients evaluated for possible MI from July 2020 through April 2021. Patients undergoing high-sensitivity cardiac troponin I testing with concentrations less than or equal to 99th percentile were included. Patients who had MI excluded by the 0/1-hour protocol could be discharged from the ED. Patients in the standard care protocol had 0- and 3-hour troponin testing and application of a modified HEART score to be eligible for discharge. The primary endpoint was the proportion of patients discharged from the ED without 30-day death or MI.
Results:
There were 13,505 and 19,104 patients evaluated in the standard care and accelerated protocol groups, respectively, of whom 19,152 (58.7%) were discharged directly from the ED. There was no significant difference in safe discharges between standard care and the accelerated protocol (59.5% vs 57.8%; adjusted odds ratio (aOR)=1.05, 95% confidence interval [CI] 0.95 to 1.16). At 30 days, there were 90 deaths or MIs with 38 (0.4%) in the standard care group and 52 (0.4%) in the accelerated protocol group (aOR=0.84, 95% CI 0.43 to 1.68).
Conclusion:
A 0/1-hour accelerated protocol using high-sensitivity cardiac troponin I did not lead to more safe ED discharges compared with standard care.
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