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Safety and efficacy of the 0/1 h pathway for myocardial infarction in the emergency department: an international, pragmatic, stepped-wedge, cluster-randomised, controlled trial
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Key result
Rapid 0/1-hour troponin pathway achieves non-inferior 30-day safety compared with the standard 0/3-hour protocol.
- OR 0.93
- 95% CI 0.77-1.13
- n=67,624
Why the trial?
The ESC 0/1-hour high-sensitivity troponin algorithm entered guidelines from observational studies, without randomised evidence that implementing it is as safe as the 0/3-hour pathway or that it actually shortens emergency department stays.
Does the 0/1 h pathway reduce emergency department length of stay and prevent 30-day death or new myocardial infarction in adults with suspected myocardial infarction compared to the 0/3 h pathway?
Population
67,624 ED presentations with suspected MI at 19 hospitals in 10 countries
Comparison
0/1 h hs-troponin pathway vs 0/3 h pathway
Design
Pragmatic stepped-wedge cluster-randomised trial, masked endpoint; NI margin OR 1.3
Follow-up
30 days
Authors
Discussion
Key questions
Author asks
Jasper Boeddinghaus38d ago
Interventional · University of Basel
What should clinicians watch for when these results land?
PRESC1SE-MI co-authorNo takes yet. Share an insight, caveat, or question.
Where experts stand
Experts see the 0/1-hour troponin pathway as safely noninferior to the 0/3-hour pathway, but the failure to shorten ED length of stay surprised many and raises questions about real-world implementation barriers.
Cardiologists broadly accept that the faster troponin pathway is safe, but the headline surprise is that it did not get patients out of the ED any sooner. The trial's lead investigator points to systemic bottlenecks like specialist review, admissions workflow, and bed availability as the likely culprits. The open question is whether the 0/1-hour pathway can deliver on its efficiency promise if hospitals redesign the surrounding processes.
Agreement
Multiple experts note that the 0/1-hour pathway met noninferiority for safety but failed to reduce ED length of stay, framing this as a disconnect between faster testing and real-world throughput.
3 clinicians say this directly
2 takes classified by contention axis so far — the map appears as more land.
Still unclear
Whether redesigning hospital workflows around specialist review, admissions, and bed availability could unlock the ED throughput benefit the 0/1-hour pathway was expected to deliver. It also remains uncertain how the new 2026 ESC Fifth Universal Definition of MI guidelines will position the 0/1-hour pathway given these results.
Key expert perspectives
Null CTA results reinforce the need for RCTs over observational hunches
Fonarow uses the trial setting to underscore that the role of imaging cannot be defined by hunches or observational findings, noting that the CTA results in this context were null and calling for rigorous RCT evidence.
Distilled from their postX post
Safety was noninferior but the implementation challenge is the real story
Van Spall highlights that noninferiority was met for safety and ED length of stay was similar across arms. She flags the discussion around trial methods and challenges of implementation trials as particularly notable.
Distilled from their postX post
JBJasper BoeddinghausEmergency medicine researcher, University of BaselResults readoutAug 30
Faster troponin alone does not fix ED throughput because bottlenecks lie elsewhere
Boeddinghaus argues the findings contradict the assumption that implementing 0/1-hour testing improves ED management. He points to other processes, including specialist review, admissions workflow, and bed availability, as the real barriers to shorter stays.
Distilled from their postOriginal post
Implication
0/1 h pathway is noninferior for 30-day safety versus 0/3 h in suspected MI; confirms guideline use without shortening emergency department length of stay.
Key Points
- To evaluate the safety and efficacy of implementing a guideline-recommended 0/1 h high-sensitivity cardiac troponin pathway compared with a standard 0/3 h pathway in emergency departments.
- Pragmatic, stepped-wedge, cluster-randomised, controlled, masked-endpoint trial (PRESC1SE-MI; NCT05649384) conducted across 19 hospitals in ten countries.
- Hospitals using standard 0/3 h blood draws transitioned to 0/1 h blood draws at 6 or 12 months, with non-inferiority safety set at an odds ratio margin of 1·3.
- Implementation of the 0/1 h pathway did not shorten emergency department length of stay compared with the 0/3 h pathway.
Evidence details
What drove the result?
| Outcome | 0/1 h pathway | 0/3 h pathway |
|---|---|---|
| Death or new type 1 MI at 30 days | 341/31,160 (1.1%) | 454/36,464 (1.2%) |
| Coprimary safety outcome · noninferior (aOR 0.93, 95% CI 0.77-1.13) | ||
| ED length of stay (median) | 309 min | 309 min |
| Coprimary efficacy outcome · not shortened (p=0.65) | ||
Limitations & tradeoffs
Representation
conducted only in hospitals that had not yet adopted the 0/1 h pathway, and only 8.7% of presentations had an adjudicated index diagnosis of MI, so results reflect a low-prevalence ED population.
Design limitations
pragmatic cluster design with unblinded treating clinicians (only endpoint adjudication was masked); the in-world abstract is truncated, so ED length-of-stay medians come from the trial summary record.
Structured PICO
Does the 0/1 h pathway reduce emergency department length of stay and prevent 30-day death or new myocardial infarction in adults with suspected myocardial infarction compared to the 0/3 h pathway?
P
Population
67,624 adults presenting to the emergency department with suspected myocardial infarction, evaluated for 30-day outcomes.
I
Intervention
0/1 h pathway (blood draws for high-sensitivity cardiac troponin at 0 h and 1 h)
C
Comparator
0/3 h pathway (blood draws at 0 h and 3 h) as standard care
O
Outcome
Coprimary safety outcome: composite of death from any cause or new type 1 myocardial infarction within 30 days. Coprimary efficacy outcome: emergency department length of stay.composite
Main Result
Odds Ratio: 0.93 (95% CI 0.77–1.13)
Absolute Event Rate: 1.1% vs 1.2%
The guideline-recommended 0/1 h troponin pathway is safe but does not reduce emergency department length of stay compared to the 0/3 h pathway.
Coverage & sources
Journal, society, and media accounts. Useful signal, not independent expert judgment.
Cite This Study
Boeddinghaus et al. (2026) conducted an RCT in Suspected myocardial infarction (n=67,624). 0/1 h pathway (blood draws at 0 h and 1 h) vs. 0/3 h pathway (blood draws at 0 h and 3 h) was evaluated on Composite of death from any cause or new type 1 myocardial infarction within 30 days (OR 0.93, 95% CI 0.77-1.13). The 0/1 h pathway met the prespecified non-inferiority criterion for the 30-day composite safety outcome of death or new myocardial infarction compared with the 0/3 h pathway (OR 0.93).
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