Accelerated -Rule-Out of acute Myocardial Infarction using prehospital copeptin and in-hospital troponin: The AROMI study

Abstract

Aims: The present acute myocardial infarction (AMI) rule-out strategies are challenged by the late temporal release of cardiac troponin. Copeptin is a non-specific biomarker of endogenous stress and rises early in AMI, covering the early period where troponin is still normal. An accelerated dual-marker rule-out strategy combining prehospital copeptin and in-hospital high-sensitivity troponin T could reduce length of hospital stay and thus the burden on the health care systems worldwide. The AROMI trial aimed to evaluate if the accelerated dual-marker rule-out strategy could safely reduce length of stay in patients discharged after early rule-out of AMI.

Methods and results: Patients with suspected AMI transported to hospital by ambulance were randomized 1:1 to either accelerated rule-out using copeptin measured in a prehospital blood sample and high-sensitivity troponin T measured at arrival to hospital or to standard rule-out using a 0 h/3 h rule-out strategy. The AROMI study included 4351 patients with suspected AMI. The accelerated dual-marker rule-out strategy reduced mean length of stay by 0.9 h (95% confidence interval 0.7-1.1 h) in patients discharged after rule-out of AMI and was non-inferior regarding 30-day major adverse cardiac events when compared to standard rule-out (absolute risk difference -0.4%, 95% confidence interval -2.5 to 1.7; P-value for non-inferiority = 0.013).

Conclusion: Accelerated dual marker rule-out of AMI, using a combination of prehospital copeptin and first in-hospital high-sensitivity troponin T, reduces length of hospital stay without increasing the rate of 30-day major adverse cardiac events as compared to using a 0 h/3 h rule-out strategy.

Trial registration: ClinicalTrials.gov NCT02666326.

Keywords: Acute myocardial infarction; Chest pain; Copeptin; Diagnosis; Diagnostic tests; Early diagnosis; High-sensitivity cardiac troponin; Myocardial infarction; NSTEMI; Non–ST-elevation myocardial infarction; Rule out; Rule-out; Troponin.

Structured Graphical Abstract

Accelerated Rule-Out of acute Myocardial Infarction using prehospital copeptin and first in-hospital high-sensitivity troponin T—the AROMI trial. RCT, randomized controlled trial; AMI, acute myocardial infarction; hs-cTnT, high-sensitivity cardiac troponin T; LOS, length of stay; MACE, major adverse cardiac events; RD, risk difference.

Figure 1

Consort flow diagram. ST-elevation MI, ST-Elevation Myocardial Infarction; ACS, Acute coronary syndrome.

Figure 2

Length of stay. (A) Distribution of length of stay in early rule-out patients (discharged within 12 h). (B) Density plot illustrating the length of hospital stay in all patients. LOS, length of stay.

Figure 3

Major adverse cardiac event non-inferiority plot. Non-inferiority plot of the standard diagnostic protocol vs. accelerated diagnostic protocol. Data are shown as point estimate and 95% confidence interval for absolute risk difference for intention-to-treat population. Non-inferiority is confirmed if confidence intervals are within the prespecified non-inferiority limit. Major adverse cardiac event consists of ‘all-cause mortality’, ‘survived cardiac arrest’, ‘confirmed acute coronary syndrome or readmission with acute coronary syndrome’, ‘non-scheduled coronary intervention’, and ‘life-threatening arrhythmias’, occurring within the time from randomization to 30 days after randomization. MACE, major adverse cardiac events; CI, confidence interval.