Accelerated dual biomarker rule-out strategy safely reduces hospital stay in patients with chest pain

The study, published in the European Heart Journal, found that the accelerated dual-marker strategy reduced the length of hospital stay by 0.9 hours compared to a standard rule-out algorithm using hs-cTnT measured at 0 and 3 hours in chest pain patients discharged after rule-out of acute myocardial infarction. It was non-inferior regarding major adverse cardiac events (MACE).

A common reason for acute admission is the suspicion of acute myocardial infarction, contributing significantly to the crowing of EDs (emergency departments) and cardiac departments worldwide. There is a need for rapid rule-out of AMI to reduce this burden on the healthcare systems. The late temporal release of cardiac troponin (cTn) and the consequent need for serial measurements of cTn challenges the present AMI rule-out strategies.

Copeptin is a non-specific biomarker of endogenous stress and is increased early in AMI, covering the early period where troponin is still normal. An accelerated dual-marker rule-out strategy that combines prehospital copeptin and in-hospital hs-cTnT could reduce the length of hospital stay and thus the worldwide burden of the health care systems.

Against the above background, Claus Kjær Pedersen, Aarhus University Hospital, Aarhus, Denmark, and colleagues aimed to evaluate if the accelerated dual-marker rule-out strategy could safely reduce the length of stay in patients discharged after early rule-out of AMI in a randomized, controlled, multicenter, investigator-initiator AROMI trial.

The study included patients with suspected AMI transported to the hospital by ambulance. They were randomized in a ratio of 1:1 to either accelerated rule-out using copeptin measured in a prehospital blood sample and high-sensitivity troponin T measured at arrival to the hospital or a standard rule-out strategy of standard rule-out using a 0 h/3 h. The AROMI study included 4351 patients with suspected AMI.

The researchers found that the accelerated dual-marker rule-out strategy reduced the mean length of stay by 0.9 h in patients discharged after the rule-out of AMI and was non-inferior regarding 30-day MACE when compared to standard rule-out (absolute risk difference −0.4%).

"In this randomized, all-comers trial conducted in an everyday clinical setup, we found that an accelerated dual-marker AMI rule-out strategy that combined prehospital copeptin and first in-hospital hs-cTnT can safely and significantly reduce the length of stay," the researchers wrote. "In the accelerated diagnostic group, absolute 30-day MACE risk was non-inferior as compared to the standard diagnostic group."

Reference:

Pedersen, C. K., Stengaard, C., Bøtker, M. T., Søndergaard, H. M., Dodt, K. K., & Terkelsen, C. J. Accelerated ­Rule-Out of acute Myocardial Infarction using prehospital copeptin and in-hospital troponin: The AROMI study. European Heart Journal. https://doi.org/10.1093/eurheartj/ehad447