SAN DIEGO – After transitioning to using the high-sensitivity troponin T assay for patients over the age of 35 years who presented to the ED with chest pain or tightness, an increased number of patients were discharged, yet no impact was observed on the time to admission and/or observation, according to a study conducted at two Philadelphia-based hospitals.
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Dr. Frederick T. Randolph
“Biomarkers have been a cornerstone of evaluating patients who present with chest pain,” Frederick T. Randolph, MD, said at the annual meeting of the American College of Emergency Physicians. “Recently in the United States, fifth-generation or high-sensitivity troponin [assays] have been approved for use. Our institution made the plan to transition to utilization of high-sensitivity troponins. At that time, we were aware of European studies that they were able to discharge a higher percentage of patients from the ED. There have been no prior studies of the clinical impact of transition to high-sensitivity troponin [assays] in the U.S.”
Dr. Randolph, director of the Chest Pain Center at Thomas Jefferson University, Philadelphia, and his colleagues performed a before and after study assessing all patients over age 35 years who presented to two hospitals with chest pain or tightness and who received a troponin assay draw in the ED. They conducted two town halls, in-services with cardiology and emergency medicine, and distributed a slide set to all providers. “There was no guidance as to who to order the troponin on,” said Dr. Randolph, who is also vice chief of emergency medicine at the university. “Essentially, the recommendation was, ‘Keep using troponins the same way you’ve been using troponins for years.’ The education was centered on how frequently we were going to order repeat troponins and how to interpret those results.”
The researchers used a 0- and 2-hour sampling strategy (unless the first value was less than 6 ng/L) and used a cut-point of 19 ng/L to define “ruled out” and a cut-point of 53 ng/L to define “consistent with acute myocardial infarction.” Indeterminate values were repeated every 2 hours. Dr. Randolph and his associates collected data for 1 year prior to transition to high-sensitivity troponins in 4,295 patients, and 2 months post transition in 769 patients. The primary outcome was discharge rate from the ED. Secondary outcome was time from presentation to admission/observation decision.
There were no statistically significant differences between the pre- and posttransition groups in the percentage of those aged 36-64 years (74% vs. 76%, respectively) or in the percentage of those who were nonwhite (61% vs. 59%). The only statistically significant difference was a higher percentage of females in the preimplementation group (49% vs. 46%; P = .02).
In all, the researchers were able to discharge 45.2% of all patients during the pretransition period, compared with 58.7% of patients in the posttransition period, for an absolute increase of 13% (P less than .001). There was no difference between the two groups in time to decision to admit or to observe (a mean of 199.1 vs. 192.2 minutes, respectively; P = .96). “Areas of future study would be to evaluate those patients who were discharged and monitor them for any changes in outcomes, to see if there is any increase in morbidity or complications,” said Dr. Randolph. “An additional research curiosity would be the downstream consequences on cost or revenue to the institution given the increased number of admissions and the decreased use of diagnostic testing such as coronary computed tomography angiography and stress testing.”
Dr. Randolph disclosed that some of the study authors have participated in multiple biomarker studies over the years. He reported having no financial disclosures.
Source: Randolph FT et al. Ann Emerg Med. 2018 Oct;72;4:S2-3. doi. 10.1016/j.annemergmed.2018.08.009.
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