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Controlled Clinical Trial
. 2021 Nov;8(2):e001769.
doi: 10.1136/openhrt-2021-001769.

Implementation of an early rule-out pathway for myocardial infarction using a high-sensitivity cardiac troponin T assay

Dennis Sandeman  1 , Maaz B J Syed  2 , Dorien M Kimenai  3 , Kuan Ken Lee  3 , Atul Anand  3 , Shruti S Joshi  3 , Lorraine Dinnel  1 , Philip R Wenham  4 , Ken Campbell  4 , Mary Jarvie  4 , Donna Galloway  4 , Mhairi Anderson  4 , Bappa Roy  5 , Jack P M Andrews  3 , Fiona E Strachan  3 , Amy V Ferry  3 , Andrew R Chapman  3 , Sarah Elsby  6 , Mark Francis  1 , Robert Cargill  1 , Anoop S V Shah  7 , Nicholas L Mills  8   9
Affiliations
Controlled Clinical Trial

Implementation of an early rule-out pathway for myocardial infarction using a high-sensitivity cardiac troponin T assay

Dennis Sandeman et al. Open Heart. 2021 Nov.

Abstract

Objectives: Patients with suspected acute coronary syndrome and high-sensitivity cardiac troponin (hs-cTn) concentrations below the limit of detection at presentation are low risk. We aim to determine whether implementing this approach facilitates the safe early discharge of patients.

Methods: In a prospective single-centre cohort study, consecutive patients with suspected acute coronary syndrome were included before (standard care) and after (intervention) implementation of an early rule-out pathway. During standard care, myocardial infarction was ruled out if hs-cTnT concentrations were <99th centile (14 ng/L) at presentation and at 6-12 hours after symptom onset. In the intervention, patients were ruled out if hs-cTnT concentrations were <5 ng/L at presentation and symptoms present for ≥3 hours or were ≥5 ng/L and unchanged within the reference range at 3 hours. We compared duration of stay (efficacy) and all-cause death at 1 year (safety) before and after implementation.

Results: We included 10 315 consecutive patients (64±16 years, 46% women) with 6642 (64%) and 3673 (36%) in the standard care and intervention groups, respectively. Duration of stay was reduced from 534 (IQR, 220-2279) to 390 (IQR, 218-1910) min (p<0.001) after implementation. At 1 year, all-cause death occurred in 10.9% (721 of 6642) and 10.4% (381 of 3673) of patients in the standard care group (referent) and intervention group, respectively (adjusted OR 1.02, 95% CI 0.88 to 1.18).

Conclusion: In patients with suspected acute coronary syndrome, implementing an early rule-out pathway using hs-cTnT concentrations <5 ng/L at presentation reduced the duration of stay in hospital without compromising safety.

Keywords: acute coronary syndrome; biomarkers; chest pain.

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Conflict of interest statement

Competing interests: DS reports that NHS Fife received a small research grant from Roche Diagnostics to support data linkage. NLM reports research grants awarded to the University of Edinburgh from Abbott Diagnostics and Siemens Healthineers outside the submitted work, and honoraria from Abbott Diagnostics, Siemens Healthineers, Roche Diagnostics and LumiraDx. The other authors declared no conflicts of interest.

Figures

Figure 1
Figure 1
Standard care and intervention pathways flow chart showing the pathway used in the standard care and intervention group. Low risk in standard pathway was <1% death at 6 months and moderate to high risk was ≥1% of death at 6 months.
Figure 2
Figure 2
Duration of stay. Density plot illustrating the duration of hospital stay for the standard care (grey) and intervention (yellow) groups stratified according to presentation high-sensitivity cardiac troponin T concentration.
Figure 3
Figure 3
Discharge at 4 hours. Proportion of patients discharged within 4 hours (green) and after 4 hours (grey) before (A) and after (B) implementation of early rule-out pathway stratified according to presentation high-sensitivity cardiac troponin T concentration. There were 68 patients with missing data (45 patients in standard group and 23 in the intervention group).
Figure 4
Figure 4
Outcomes. All-cause death at 1 year in all patients admitted following implementation of an early rule-out pathway compared with standard care, and stratified by troponin concentrations at presentation <5 ng/L, between 5 and 14 ng/L, and >14 ng/L. Model 1=crude unadjusted model; model 2=model 1+age+sex; model 3=model 2+sex, creatinine, diabetes mellitus, and a history of myocardial infarction, heart failure or cerebrovascular disease. hs-cTnT, high-sensitivity cardiac troponin T.
See this image and copyright information in PMC

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