Rule-out of non-ST-segment elevation acute coronary syndrome by a single, pre-hospital troponin measurement: a randomized trial

Abstract

Aims Patients with suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) are routinely transferred to the emergency department (ED). A clinical risk score with point-of-care (POC) troponin measurement might enable ambulance paramedics to identify low-risk patients in whom ED evaluation is unnecessary. The aim was to assess safety and healthcare costs of a pre-hospital rule-out strategy using a POC troponin measurement in low-risk suspected NSTE-ACS patients. Methods and results This investigator-initiated, randomized clinical trial was conducted in five ambulance regions in the Netherlands. Suspected NSTE-ACS patients with HEAR (History, ECG, Age, Risk factors) score ≤3 were randomized to pre-hospital rule-out with POC troponin measurement or direct transfer to the ED. The sample size calculation was based on the primary outcome of 30-day healthcare costs. Secondary outcome was safety, defined as 30-day major adverse cardiac events (MACE), consisting of ACS, unplanned revascularization or all-cause death. : A total of 863 participants were randomized. Healthcare costs were significantly lower in the pre-hospital strategy (€1349 ± €2051 vs. €1960 ± €1808) with a mean difference of €611 [95% confidence interval (CI): 353–869; P < 0.001]. In the total population, MACE were comparable between groups [3.9% (17/434) in pre-hospital strategy vs. 3.7% (16/429) in ED strategy; P = 0.89]. In the ruled-out ACS population, MACE were very low [0.5% (2/419) vs. 1.0% (4/417)], with a risk difference of −0.5% (95% CI −1.6%–0.7%; P = 0.41) in favour of the pre-hospital strategy. Conclusion Pre-hospital rule-out of ACS with a POC troponin measurement in low-risk patients significantly reduces healthcare costs while incidence of MACE was low in both strategies. Trial registration Clinicaltrials.gov identifier NCT05466591 and International Clinical Trials Registry Platform id NTR 7346.

Direct admission versus interhospital transfer for revascularisation in non‐ST‐segment elevation myocardial infarction

“…The Royal Free Hospital managed to reduce median time to ICA through this pathway to 2.8 h (IQR 1.5–9) compared to 60 h (IQR 33–116) with use of a pathway similar to the pathway evaluated in our study 2 . Additionally, a two recently conducted randomized trials by Camaro et al 18 and Dawson et al 19 demonstrated that prehospital rule‐out of ACS with a point‐of‐care troponin measurement in chest pain patient's notably reduced healthcare expenditure. However, there is not yet consensus on the most ideal form of prehospital triage as several methods are still in the early stages of development and trials are currently being conducted 20 .…”

“…The Royal Free Hospital managed to reduce median time to ICA through this pathway to 2.8 h (IQR 1.5-9) compared to 60 h (IQR 33-116) with use of a pathway similar to the pathway evaluated in our study 2. Additionally, a two recently conducted randomized trials by Camaro et al18 and Dawson et al19 demonstrated that prehospital rule-out of ACS with a point-of-care troponin…”

Journal update monthly top five

“…In low-risk patients, a single high-sensitivity troponin has been sufficient to ‘rule out’ acute coronary syndrome (ACS) in the ED. This multicentre, open-label, randomised controlled trial (RCT) across five ambulance regions in the Netherlands assessed if the use of a prehospital point-of-care (POC) troponin in low-risk patients with chest pain could significantly reduce 30-day healthcare costs 2…”

HART-c: Prehospital triage via hospital consultation—the future lies in the ambulance

“…It is expected that new high-sensitive point-of-care troponin devices can even further improve the safety of prehospital stratification [5][6][7]. The recent ARTICA trial showed that this is also costeffective [8]. This way, up to 20-30% of patients who call the emergency telephone number for the Netherlands (112) because of chest pain can safely stay at home.…”

“…Hospitals are experts at ruling out diseases and work more defensively: often additional CT scans, laboratory tests and even cardiac catheterisations are performed on these low-risk patients, without additional value but at a cost of about 7500 euro per patient. It is estimated that 30-50 million euro could be saved nationwide when these unnecessary hospital admissions are prevented [8,11].…”