Outcomes of Patients That Rule Out Within One Hour Using High-Sensitivity Cardiac Troponin Protocols

Document Type

Conference Proceeding

Publication Date

4-20-2023

Publication Title

Acad Emerg Med

Abstract

Background and Objectives: In the United States (US), emergency departments (ED) have recently implemented high-sensitivity cardiac troponin (hs-cTn) protocols to rapidly rule-out myocardial infarction (MI) without the use of cardiac risk scores. We compared cardiovascular outcomes in patients that succeeded or failed to rule-out for MI within 1-h using an accelerated hs-cTn protocol. Methods: This was a secondary analysis of the RACE-IT trial, a stepped-wedge pragmatic trial performed across 9 EDs in Southeast Michigan. Eligibility mirrored real-world use of hs-cTn testing by including all consecutive adults with a hs-cTn and electrocardiogram and excluding those with ST-segment elevation MI, trauma, and pregnancy. The trial tested implementation of an accelerated protocol using hs-cTn, in which patients could rule-out for MI within 1-h based on very low hs-cTn values and were eligible for ED discharge without application of a cardiac risk score. In this analysis, we compared patients in the accelerated protocol who ruled-out for MI within 1-h to those that did not. Outcomes were followed for 30-days and included death or MI, ED discharge, cardiac stress testing, and cardiac revascularization. Analysis included generalized linear mixed models to compare the two arms and determine adjusted odds ratios (aOR) with 95% confidence intervals (CI). Results: Analysis included 19,103 patients, 10,444 in the 1-h rule-out group and 8659 not ruled-out within the hour. In adjusted analysis, patients in the 1-h group had higher odds of safe ED discharge (aOR 2.87, 95% CI 2.62-3.14). These patients also had shorter ED stays, with an expected change in length of stay of -22.3% (95% CI -23.62% to -20.94%). While patients in the 1-h rule-out group had higher adjusted odds of cardiac stress testing (aOR 1.47, 95% CI 1.22-1.76), they had overall low rates of cardiac revascularization. Nineteen (0.18%) had percutaneous and 3 (0.03%) had surgical revascularization. Death or MI was less common in the 1-h group (17, 0.20%) compared to others (35, 0.81%), though this did not meet statistical significance (aOR 0.67, 95% CI 0.35-1.28). Conclusion: In an accelerated protocol to manage patients with suspected MI, patients that rule-out within 1 h had higher safe discharge rates and decreased length of stay. Further study is warranted to determine why these patients had modestly higher odds of cardiac stress testing within 30 day.

Volume

30

First Page

240

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