Use of high-sensitivity cardiac troponin I for risk stratification and early rule out of myocardial infarction (MI) in patients with suspected acute coronary syndrome (ACS) reduced length of stay and hospital readmissions without increasing adverse cardiac events, according to findings from the HISTORIC trial presented at ESC Congress 2019 and published in Circulation.

The study was based on 32,837 patients (47 percent female, age 61 years) with suspected ACS across 10 hospitals in Scotland. Researchers compared use of a single high-sensitivity cardiac troponin test at presentation (<5 ng/L) to rule out MI, with guideline-recommended standard care that included serial testing at presentation and six to 12 hours later. The primary efficacy outcome was length of hospital stay, defined as the length of time from initial presentation to the emergency department (ED) until final discharge. The primary safety outcome was MI or cardiac death after discharge at 30 days and one year.

Results found the early rule-out pathway reduced the length of stay from 10.1 hours to 6.8 hours, while also increasing the proportion of patients discharged from the ED without hospital admission from 53 percent to 74 percent. At 30 days, the primary safety outcome occurred in 0.4 percent and 0.3 percent of patients before and after implementation of the early rule-out pathway, respectively. At one year, MI or cardiac death occurred in 2.6 percent of patients before the early-rule out implementation compared with 1.8 percent of patients after.

"This is the first randomized controlled trial to evaluate the efficacy and safety of an early rule-out pathway," said Nicholas Mills, MB, BCh, principal investigator for the study. "Introducing the pathway into routine clinical practice reduced length of stay by more than three hours and increased the proportion of patients discharged from the emergency department by over 50 percent." He added that in countries like the U.S. where more than 20 million patients are seen in the ED with suspected ACS each year, just reducing the length of stay by three hours could save more than $3.6 billion annually on bed occupancy alone.

Keywords: ESC 19, ESC Congress, Myocardial Infarction, Percutaneous Coronary Intervention, Angiography

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