Limit of detection of troponin discharge strategy versus usual care: randomised controlled trial

Heart. 2020 Oct;106(20):1586-1594. doi: 10.1136/heartjnl-2020-316692. Epub 2020 May 5.

Abstract

Introduction: The clinical effectiveness of a 'rule-out' acute coronary syndrome (ACS) strategy for emergency department patients with chest pain, incorporating a single undetectable high-sensitivity cardiac troponin (hs-cTn) taken at presentation, together with a non-ischaemic ECG, remains unknown.

Methods: A randomised controlled trial, across eight hospitals in the UK, aimed to establish the clinical effectiveness of an undetectable hs-cTn and ECG (limit of detection and ECG discharge (LoDED)) discharge strategy. Eligible adult patients presented with chest pain; the treating clinician intended to perform investigations to rule out an ACS; the initial ECG was non-ischaemic; and peak symptoms occurred <6 hours previously. Participants were randomised 1:1 to either the LoDED strategy or the usual rule-out strategy. The primary outcome was discharge from the hospital within 4 hours of arrival, without a major adverse cardiac event (MACE) within 30 days.

Results: Between June 2018 and March 2019, 632 patients were randomised; 3 were later withdrawn. Of 629 patients (age 53.8 (SD 16.1) years, 41% women), 7% had a MACE within 30 days. For the LoDED strategy, 141 of 309 (46%) patients were discharged within 4 hours, without MACE within 30 days, and for usual care, 114 of 311 (37%); pooled adjusted OR 1.58 (95% CI 0.84 to 2.98). No patient with an initial undetectable hs-cTn had a MACE within 30 days.

Conclusion: The LoDED strategy facilitates safe early discharge in >40% of patients with chest pain. Clinical effectiveness is variable when compared with existing rule-out strategies and influenced by wider system factors.

Trial registration number: ISRCTN86184521.

Keywords: acute coronary syndromes; acute myocardial infarction; health care delivery; health care economics; quality and outcomes of care.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acute Coronary Syndrome / blood
  • Acute Coronary Syndrome / diagnosis*
  • Acute Coronary Syndrome / therapy
  • Adult
  • Aged
  • Angina Pectoris / blood
  • Angina Pectoris / diagnosis*
  • Angina Pectoris / therapy
  • Biomarkers / blood
  • Cardiology Service, Hospital
  • Clinical Decision Rules*
  • Electrocardiography*
  • Emergency Service, Hospital
  • Female
  • Humans
  • Length of Stay
  • Male
  • Middle Aged
  • Patient Discharge*
  • Predictive Value of Tests
  • Prospective Studies
  • Risk Assessment
  • Risk Factors
  • Time Factors
  • Troponin / blood*
  • United Kingdom

Substances

  • Biomarkers
  • Troponin

Associated data

  • ISRCTN/ISRCTN86184521