Single troponin test enough to discharge suspected heart attack patients from ED: JAMA
USA: A single negative troponin test versus serial troponin testing appears safe in ruling out acute coronary syndrome (ACS) in patients presented to emergency department (ED) with chest pain, finds a recent study. According to the study, published in the JAMA Network Open, there was no difference in rates of 30-day cardiac mortality and acute myocardial infarction with the use of single versus serial troponin testing.
The researchers reported that 30-day rate of acute MI or cardiac mortality was similar regardless of whether patients had one troponin test or underwent serial testing in the emergency department (0.4% in both groups).
"Our findings suggest that physician discretion to order serial or single troponin tests for the management of ED patients suspected to have acute coronary syndrome appears safe and is a reasonable strategy for improving efficiency without an adverse association with patient outcomes," wrote the authors.
Chest pain is one of the common reasons for presenting to the ED. However, most of the patients are at low ACS risk, with low rates of cardiac adverse outcomes. Biomarker testing with troponin levels plays an important role in initial ACS assessment. Although, in clinical practice, serial troponin testing can improve the ACS diagnosis, some patients deemed to be low risk are discharged after a single negative troponin test result. Maereg Wassie, Los Angeles Medical Center, Los Angeles, and colleagues reported the clinical outcomes of patients discharged after a single negative troponin test result compared with patients discharged after serial troponin measurements.
For the purpose, the researchers performed a retrospective cohort study of ED encounters from May 5, 2016, to December 1, 2017, across 15 community EDs within an integrated health care system in southern California. The study included 27 918 adult ED encounters in which patients were evaluated for suspected ACS with a HEART (history, electrocardiogram, age, risk factors, and troponin) score and an initial conventional troponin-I measurement below the level of detection (<0.02 ng/mL).
The primary outcome was acute myocardial infarction or cardiac mortality.
Key findings of the study include:
- Of patients with an initial troponin measurement below the level of detection, 14 459 (51.8%) were discharged after a single troponin measurement, and 13 459 (48.2%) underwent serial troponin tests.
- After adjustment for cardiac risk factors and comorbidities, there was no statistically significant difference in the primary outcome of acute myocardial infarction or cardiac mortality within 30 days between the 2 groups (single troponin, 56 vs serial troponin, 52; adjusted odds ratio).
- Patients discharged after a single troponin test had lower rates of coronary artery bypass graft (adjusted odds ratio, 0.24) and invasive coronary angiography (adjusted odds ratio, 0.46).
"This study suggests that patients are routinely discharged from the ED after a single negative troponin test result, and when compared with serial troponin testing, a single troponin test appears safe based on current physician decision-making, with no difference in rates of 30-day cardiac mortality and acute myocardial infarction, which are low in both groups," concluded the authors.
The study titled, "Single vs Serial Measurements of Cardiac Troponin Level in the Evaluation of Patients in the Emergency Department With Suspected Acute Myocardial Infarction," is published in the journal JAMA Network Open.
DOI: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2776718
