Clinical outcomes for chest pain patients discharged home from emergency departments using high-sensitivity versus conventional cardiac troponin assays
Lau G, Koh M, Kavsak PA, Schull MJ, Armstrong DWJ, Udell JA, Austin PC, Wang X, Ko DT. Am Heart J. 2019; 221:84-94. Epub 2019 Dec 11. DOI: https://doi.org/10.1016/j.ahj.2019.12.007
Background — High-sensitivity cardiac troponin (hs-cTn) assays enhance detection of lower circulating troponin concentrations, but the impact on outcomes in clinical practice is unclear. Our objective was to compare outcomes of chest pain patients discharged from emergency departments (EDs) using hs-cTn and conventional troponin (cTn) assays.
Methods — We conducted an observational study of chest pain patients aged 40–105 years who presented to an ED from April 1, 2013, to March 31, 2017, and were discharged home. We compared 30-day and 1-year outcomes of EDs that used hs-cTn versus cTn assays. The primary outcome was a composite of all-cause death, myocardial infarction or unstable angina. Comparisons were conducted with (1) no adjustment; (2) adjustment for demographic, socioeconomic, and hospital characteristics; and (3) full clinical adjustment.
Results — Among the 394,910 patients, 62,138 (15.7%) were evaluated at hs-cTn EDs and 332,772 (84.3%) were evaluated at cTn EDs. Patients discharged from hs-cTn EDs were less likely to have diabetes, hypertension, or prior heart disease. At 30-days, the unadjusted primary outcome rate was lower in hs-cTn EDs (0.9% vs. 1.0%, P < 0.001). The 30-day hazard ratios (HRs) for the primary outcome were 0.84 (95% CI 0.77–0.92) for no adjustment and 0.98 (95% CI 0.88–1.08) for full adjustment. Over 1 year, patients discharged from hs-cTn EDs had significantly fewer primary outcomes (3.7% vs. 4.1%, P < 0.001), and lower HR 0.93 (95% CI 0.89–0.98) even after full adjustment.
Conclusions — Hs-cTn testing was associated with a significantly lower adjusted hazard of myocardial infarction, angina, and all-cause hospitalization at 1 year but not 30 days.