A Rule-Out Strategy Based on High-Sensitivity Troponin and HEART Score Reduces Hospital Admissions - 26/04/19
, Bertil Lindahl, MD, PhD e, f, Kai M. Eggers, MD, PhD e, Mats Frick, MD, PhD a, d, Rikard Linder, MD, PhD b, Henrik B. Löfmark, MD b, Arne Martinsson, MD, PhD g, Dina Melki, MD, PhD h, Nondita Sarkar, MD, PhD c, h, Per Svensson, MD, PhD c, i, Tomas Jernberg, MD, PhD bAbstract |
Study objective |
We evaluate whether a combination of a 1-hour high-sensitivity cardiac troponin algorithm and History, ECG, Age, Risk Factors, and Troponin (HEART) score reduces admission rate (primary outcome) and affects time to discharge, health care–related costs, and 30-day outcome (secondary outcomes) in patients with symptoms suggestive of an acute coronary syndrome.
Methods |
This prospective observational multicenter study was conducted before (2013 to 2014) and after (2015 to 2016) implementation of a strategy including level of high-sensitivity cardiac troponin T or I at 0 and 1 hour, combined with the HEART score. Patients with a nonelevated baseline high-sensitivity cardiac troponin level, a 1-hour change in high-sensitivity cardiac troponin T level less than 3 ng/L, or high-sensitivity cardiac troponin I level less than 6 ng/L and a HEART score less than or equal to 3 were considered to be ruled out of having acute coronary syndrome. A logistic regression analysis was performed to adjust for differences in baseline characteristics.
Results |
A total of 1,233 patients were included at 6 centers. There were no differences in regard to median age (64 versus 63 years) and proportion of men (57% versus 54%) between the periods. After introduction of the new strategy, the admission rate decreased from 59% to 33% (risk ratio 0.55 [95% confidence interval {CI} 0.48 to 0.63]; odds ratio 0.33 [95% CI 0.26 to 0.42]; adjusted odds ratio 0.33 [95% CI 0.25 to 0.42]). The median hospital stay was reduced from 23.2 to 4.7 hours (95% CI of difference –20.4 to –11.4); median health care–related costs, from $1,748 to $1,079 (95% CI of difference –$953 to –$391). The number of clinical events was very low.
Conclusion |
In this before-after study, clinical implementation of a 1-hour high-sensitivity cardiac troponin algorithm combined with the HEART score was associated with a reduction in admission rate and health care burden, with very low rates of adverse clinical events.
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| Please see page 492 for the Editor’s Capsule Summary of this article. |
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| Supervising editor: Clare L. Atzema, MD, MSc. Specific detailed information about possible conflict of interest for individual editors is available at editors. |
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| Author contributions: BL and TJ were responsible for the design of the FASTEST) study. All authors contributed to the enrollment of patients. LL and TJ were responsible for analyzing the data and writing the article. All authors contributed to the interpretation of the results, provided intellectual contribution to the article and critically reviewed the article. All authors have read and approved the final article and take final responsibility for the decision to submit for publication in the present form. LL takes responsibility for the paper as a whole. |
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| All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. |
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| Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The FASTEST study received research funding from the European Commission Seventh Framework Programme (BestAgeing), Brussels, Belgium; the Swedish Heart-Lung Foundation, Stockholm, Sweden; the Stockholm County Council (ALF Project), Stockholm, Sweden; Fiomi Diagnostics, Uppsala, Sweden; bioMérieux, Marcy L’Etoile, France; and Radiometer, Copenhagen, Denmark. Dr. Lindahl reports receiving research support from Fiomi Diagnostics and bioMérieux and serving as a consultant for Fiomi Diagnostics, bioMérieux, Roche Diagnostics, Philips, and Thermo-Fischer. Dr. Eggers reports receiving honoraria from Abbott Laboratories and serving as a consultant for Abbott Laboratories and Fiomi Diagnostics. |
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| The funders did not participate in the study design, conduct of the study, analysis and interpretation of the data, preparation of the article, article review, or approval of the article. |
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Vol 73 - N° 5
P. 491-499 - mai 2019 Retour au numéro
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