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Observational Study
. 2015 Jul;101(13):1041-6.
doi: 10.1136/heartjnl-2014-307288. Epub 2015 Feb 17.

A novel diagnostic protocol to identify patients suitable for discharge after a single high-sensitivity troponin

Edward W Carlton  1 , Louise Cullen  2 , Martin Than  3 , James Gamble  4 , Ahmed Khattab  5 , Kim Greaves  6
Affiliations
Observational Study

A novel diagnostic protocol to identify patients suitable for discharge after a single high-sensitivity troponin

Edward W Carlton et al. Heart. 2015 Jul.

Abstract

Objective: To establish whether a novel accelerated diagnostic protocol (ADP) for suspected acute coronary syndrome (ACS) could successfully identify low-risk patients suitable for discharge after a single high-sensitivity troponin T (hs-cTnT) taken at presentation to the emergency department. We also compared the diagnostic accuracy of this ADP with strategies using initial undetectable hs-cTnT.

Methods: This prospective observational study evaluated the ability of the Triage Rule-out Using high-Sensitivity Troponin (TRUST) ADP to identify low-risk patients with suspected ACS. The ADP incorporated a single presentation hs-cTnT of <14 ng/L, a non-ischaemic ECG and a modified Goldman risk score. Diagnostic performance of the ADP was compared with the detection limit cut-offs of hs-cTnT (<5 ng/L and <3 ng/L). The primary end point was fatal/non-fatal acute myocardial infarction (AMI) within 30 days.

Results: 960 participants were recruited, mean age 58.0 years, 80 (8.3%) had an AMI. The TRUST ADP classified 382 (39.8%) as low-risk with a sensitivity for identifying AMI of 98.8% (95% CI 92.5% to 99.9%). hs-cTnT detection limits (<5 ng/L and <3 ng/L) had a sensitivity of 100% (94.3 to 100) and 100% (94.4 to 100), respectively. The TRUST ADP identified more patients suitable for early discharge at 39.8% vs 29.3% (<5 ng/L) and 7.9% (<3 ng/L) (p<0.001) with a lower false-positive rate for AMI detection; specificity 43.3% (95% CI 42.7% to 43.4%) vs 32.0% (95% CI 31.5% to 32.0%) and 8.6% (95% CI 8.1% to 8.6%), respectively.

Conclusions: The TRUST ADP, which incorporates structured risk-assessment and a single presentation hs-cTnT blood draw, has potential to allow early discharge in 40% of patients with suspected ACS and has greater clinical utility than undetectable hs-cTnT strategies.

Trial registration number: ISRCTN No. 21109279.

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Figures

Figure 1
Figure 1
Participant recruitment flow chart. The 132 patients who missed the consent process were similar in age, gender, risk factors and m-Goldman scores (p>0.05 for all). ADP, accelerated diagnostic protocol; AMI, acute myocardial infarction; TRUST, Triage Rule-out Using high-Sensitivity Troponin.
See this image and copyright information in PMC

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