Safety of Using Risk Stratification Along With High-Sensitivity Cardiac Troponin in the Emergency Department: A
Ziwen Li1, Dimitrios Doudesis2, Anda Bularga1
1BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
Insights
High-sensitivity cardiac troponin risk stratification effectively reduces hospital stay and increases emergency department discharges for patients with suspected acute coronary syndrome. Discharged patients show a lower risk of future myocardial infarction or cardiac death.
Area of Science:
- Cardiology
- Emergency Medicine
- Diagnostic Testing
Background:
- Early rule-out pathways for myocardial infarction using high-sensitivity cardiac troponin (hs-cTn) decrease hospital stay and admissions.
- Uncertainty exists regarding the effectiveness of hs-cTn in low-to-intermediate risk patients and the long-term safety of discharged individuals.
Purpose of the Study:
- To evaluate the effectiveness and safety of hs-cTn risk stratification in patients with suspected acute coronary syndrome (ACS) deemed low and intermediate risk.
Main Methods:
- Secondary analysis of a stepped-wedge cluster-randomized controlled trial involving 31,492 patients with suspected ACS.
- Patients were stratified as low (<5 ng/L) or intermediate (5 ng/L to 99th percentile) risk using hs-cTn.
- Primary outcomes were length of hospital stay (effectiveness) and subsequent myocardial infarction or cardiac death at 1 year (safety).
Main Results:
- Hs-cTn implementation reduced length of stay in both low-risk (2.2 hours) and intermediate-risk (4.8 hours) patients (P < 0.001).
- Emergency department discharge rates increased significantly in low-risk (adjusted OR: 3.31) and intermediate-risk (adjusted OR: 2.06) patients.
- Discharged patients had a lower 1-year risk of myocardial infarction or cardiac death (aHR: 0.65), irrespective of initial risk stratification.
Conclusions:
- Risk stratification with hs-cTn is effective in reducing hospital stay and increasing emergency department discharges for low- and intermediate-risk ACS patients.
- Patients discharged following hs-cTn risk stratification exhibit a reduced risk of subsequent major adverse cardiac events at one year.
Background:
Implementation of an early rule-out pathway for myocardial infarction using high-sensitivity cardiac troponin to risk stratify patients reduces length of stay and hospital admission. Whether gains are similar in low- and intermediate-risk patients and those discharged were correctly identified as being at lower risk of future cardiovascular events is uncertain.
Objectives:
This study sought to evaluate the effectiveness and safety of risk stratification with high-sensitivity cardiac troponin in patients with suspected acute coronary syndrome stratified as low and intermediate risk.
Methods:
In this secondary analysis of a stepped-wedge cluster-randomized controlled trial, we evaluated the effectiveness and safety of risk stratification with high-sensitivity cardiac troponin in 31,492 consecutive patients who presented with suspected acute coronary syndrome and identified as low (<5 ng/L) or intermediate (5 ng/L to 99th percentile) risk at presentation. The primary effectiveness outcome was length of hospital stay. The primary safety outcome was subsequent myocardial infarction or cardiac death at 1 year.
Results:
Of 31,492 patients (59 ± 17 years, 45% women), 17,299 (54.9%) and 14,193 (45.1%) were low and intermediate risk, respectively. Following implementation, length of stay was reduced in low-risk (6.9 ± 3.2 vs 4.7 ± 2.8 hours: difference 2.2; 95% CI: 0.7-3.7 hours) and intermediate-risk (15.8 ± 4.7 vs 11.0 ± 4.9 hours: difference 4.8; 95% CI: 3.8-5.8 hours) patients (P < 0.001 for both). Discharge from the emergency department increased in low-risk (62% [4,962 of 7,941] vs 83% [7,747 of 9,358]; adjusted OR: 3.31; 95% CI: 3.06-3.57) and intermediate-risk (36% [2,445 of 6,759] vs 55% [4,095 of 7,434]; adjusted OR: 2.06; 95% CI: 1.92-2.21) patients. Following implementation, patients discharged were at lower risk of myocardial infarction or cardiac death at 1 year (1.5% [112 of 7,407] vs 1.0% [124 of 11,842]; adjusted HR [aHR]: 0.65; 95% CI: 0.50-0.86), whether stratified as low (0.6% vs 0.3%; aHR: 0.46; 95% CI: 0.26-0.83) or intermediate (3.4% vs 2.4%; aHR: 0.74; 95% CI: 0.55-0.99) risk at presentation.
Conclusions:
Risk stratification with high-sensitivity cardiac troponin reduced length of stay and increased discharge from the emergency department in both low- and intermediate-risk patients with suspected acute coronary syndrome. Patients discharged from the emergency department were at lower risk of subsequent myocardial infarction or cardiac death at 1 year. (High-Sensitivity Cardiac Troponin on Presentation to Rule Out Myocardial Infarction [HiSTORIC]; NCT03005158).
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