A Novel accelerated diagnostic protocol to identify emergency department patients with chest pain who may be suitable for discharge after a single high-sensitivity troponin TRUST:Triage Rule-out Using high-sensitivity Troponin Chest Pain Study.

Abstract

Background Chest pain makes up a quarter of medical admissions in the United Kingdom. A diagnostic strategy that prevents unnecessary hospital admission in a large proportion of this patient group would have significant benefits for healthcare services by reducing hospital admission rates, ED overcrowding, duplication of staff time and resource use. A clinically applicable protocol that allows the discharge of a significant proportion of patients after a single blood draw at presentation to the emergency department remains an attractive yet elusive goal. Objective To establish whether a novel accelerated diagnostic protocol (ADP) for suspected acute coronary syndrome (ACS) could successfully identify low-risk patients suitable for discharge after a single high-sensitivity troponin T (hs-cTnT) taken at presentation to the Emergency Department (ED). Comparison of the diagnostic accuracy of this ADP with strategies utilising initial undetectable hs-cTnT was made. Methods This prospective observational study evaluated the ability of the Triage Rule-out Using high-Sensitivity Troponin (TRUST) ADP to identify low-risk patients with suspected ACS. The ADP incorporated a single presentation hs-cTnT of <14ng/L, a non-ischaemic electrocardiogram and a modified Goldman risk score. Diagnostic performance of the PhD Thesis. Dr Edward W. Carlton ADP was compared with the detection limit cut-offs of hs-cTnT (<5ng/L and <3ng/L). The primary endpoint was major adverse cardiac events (MACE) occurring within 30 days. Results 960 participants were recruited, mean age 58.0 years, 97 (10.1%) had MACE. The TRUST ADP classified 382 (39.8%) as low-risk with a sensitivity for identifying MACE of 99.0% (95%CI 93.7-99.9). Hs-cTnT detection limits (<5ng/L and <3ng/L) had a sensitivity of 96.8% (90.6-99.2) and 98.9% (93.8-99.9) respectively. The TRUST ADP identified more patients suitable for early discharge at 39.8% vs 29.3% (<5ng/L) and 7.9% (<3ng/L) (P<0.001) with a lower false-positive rate for MACE detection; specificity 44.1% (95%CI 43.6-44.3) vs 32.3% (95%CI 31.6-32.6) and 8.7% (95%CI 8.1-8.8) respectively. Conclusion The TRUST ADP, which incorporates structured risk-assessment and a single presentation hs-cTnT blood draw, has potential to allow early discharge in 40% of patients with suspected ACS and has greater clinical utility than undetectable hs-cTnT strategies.