Limit of detection of troponin discharge strategy versus usual care: randomised controlled trial

Edward Watts Carlton, Jenny Ingram, Hazel Taylor, Joel Glynn, Rebecca Kandiyali, Sarah Campbell, Lucy Beasant, Shahid Aziz, Peter Beresford, Jason Kendall, Adam Reuben, Jason E Smith, Rebecca Chapman, Siobhan Creanor, Jonathan Richard Benger

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Abstract

IntroductionThe clinical effectiveness of a “rule-out” strategy for emergency department patients with chest pain, incorporating a single undetectable high-sensitivity troponin (hs-cTn) taken at presentation, together with a non-ischaemic electrocardiogram (ECG), remains unknown.
MethodsThis randomised controlled trial, across eight hospitals in the UK, aimed to establish the clinical effectiveness of an undetectable hs-cTn and ECG (LoDED) discharge strategy. Eligible patients presented with chest pain, were adults, the treating clinician intended to perform investigations to rule out an acute coronary syndrome, the initial ECG was non-ischaemic and peak symptoms occurred <6 hours before arrival. Participants were randomised 1:1 to either the LoDED strategy or the usual rule-out strategy. The primary outcome was discharge from hospital within four hours of arrival, without a Major Adverse Cardiac Event (MACE) within 30 days.
ResultsBetween June 2018 and March 2019, 632 patients were randomised, three were later withdrawn. Of 629 patients (age 53.8 [SD 16.1] years, 41% women), 7% had a MACE within 30 days. For the LoDED strategy 141 of 309 [46%] patients were discharged within four hours, without MACE within 30 days, and for usual care 114 of 311 [37%]; pooled adjusted odds ratio 1.58 (95% CI 0.84-2.98). No patient with an initial undetectable hs-cTn had a MACE within 30 days.
ConclusionThe LoDED strategy facilitates safe early discharge in >40% of chest pain patients. Clinical effectiveness is variable when compared to existing rule-out strategies and influenced by wider system factors.
Original languageEnglish
Number of pages9
JournalHeart
DOIs
Publication statusPublished - 5 May 2020

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