High sensitivity troponin values rapidly rule-out myocardial infarction and allow for ed discharge in a higher risk patient population compared to contemporary practice
Nowak RM, Christenson RH, Jacobsen G, Apple F, McCord J, Limkakeng A, Singer A, Peacock WF, and DeFilippi CR. High sensitivity troponin values rapidly rule-out myocardial infarction and allow for ed discharge in a higher risk patient population compared to contemporary practice. Journal of the American College of Cardiology 2020; 75(11):66.
J Am Coll Cardiol
Background The multicenter High Sensitivity Cardiac Troponin I (hs-cTnI) study (HIGH-US) reported a 1 hour hs-cTnI algorithm in the Emergency Department (ED) rule-out rate of 50.4% for AMI (negative predictive value 99.7%) and 30 day incidence of AMI/death of 0.2%. We sought to determine factors associated with ED discharge versus observation/inpatient placements in these patients. Methods 2113 consenting adults were enrolled from 2015-2016 in 29 medical centers with suspicion for AMI. Baseline and 1 hour plasma samples were analyzed using the Siemens Atellica hs-cTnI assay (overall 99th %ile 45.0 ng/L). AMI diagnosis was independently adjudicated using local contemporary troponin assays and 30 day clinical information. Clinical variables used to aid in disposition decision making were compared in AMI ruled out patients. Results 1020 (48.3%) individuals were ruled out in for AMI in 1 hour. Of these 584 (57.3%) were discharged home while 436 (42.7%) were placed in observation/inpatient beds. The latter group were older with more hypertension, diabetes, smoking, heart or renal failure, personal or family history of coronary artery disease, prior AMI or revascularization and other vascular diseases (Table). Conclusion ED physicians were less likely to discharge home patients ruled out for AMI if they had traditional risk factors for CAD. Compared to contemporary practice hs-cTnI use allows more patients with higher risk clinical profiles to be discharged home than based on traditional assessments.