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Early rule-out alogrithm for MI patients proves safe and effective

ESC 2019
Implementation of an early indicator for ruling out myocardial infarction (MI) in patients with suspected acute coronary syndrome (ACS), incorporating a single high-sensitivity cardiac troponin (hs-cTn) test at presentation with risk stratification and diagnostic thresholds, is both effective and safe.

The HiSTORIC trial was a stepped-wedge cluster randomised controlled trial conducted in 7 hospitals across Scotland. Randomisation was performed at the hospital level and not per patient; this resulted in enrolment of all consecutive patients undergoing hs-cTnI testing for suspected ACS in the emergency room. MI was ruled out if hs-cTnI concentrations were <5 ng/L at presentation or between 5 ng/L and the 99thcentile with a change <3 ng/L at3hours (High-STEACS pathway). Co-primary endpoints of the study were length of stay (efficacy) and MI or cardiac death after discharge (safety) within 1 year of follow-up. A total of 31,492 patients with cTnI concentrations <99th centile participated. Results demonstrated that the use of this algorithm reduced the length of stay by >3 hours (from 10.1 to 6.8hours;P<0.001). Also, the relative number of patients discharged from the emergency room increased from 53% to 74% (P<0.001).The event rate for the safety outcome measure was similar before and after implementation of the early rule-out algorithm (respectively, 0.4% and 0.3% at 30 days, and 2.7% and 1.8% at 1year). Interestingly, the rate of adherence to the pathway was between 86%-92% for three pre-specified adherence measures. Thus, the HiSTORIC study provided the first randomised controlled trial evidence that a single hs-cTn test can be used to safely and effectively rule out MI at presentation[1].

1. Mills NL. HiSTORIC -High-Sensitivity cardiac Troponin On presentation to Rule out myocardial InfarCtion: A stepped-wedge cluster randomised controlled trial. Abstract 2309.ESC Congress 2019, 31 Aug-4 Sept, Paris, France.

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