Key result
Omitting further testing in suspected MI with HsTnI <5 ng/dl shows similar 360-day mortality.
Why the study?
The study examined whether a maximal HsTnI under 5 ng/dl in a hemodynamically stable patient is sufficient to discharge a patient without further testing.
Does discharge without further testing compared to admission for further testing affect mortality in patients with suspected myocardial infarction and HsTnI < 5 ng/dl?
Cohort (n=7,925)
No
Does discharge without further testing compared to admission for further testing affect mortality in patients with suspected myocardial infarction and HsTnI < 5 ng/dl?
Although mortality is very low in patients with suspected MI and HsTnI < 5 ng/dl, further testing identifies a small proportion of patients requiring revascularization, leading authors to question rapid rule-out algorithms in those with cardiovascular risk factors.
Introduction Since the introduction of High sensitive troponin assays, many studies showed that patients presenting to the ED with cardiac chest pain and HsTnI under 5 ng/dl have very good prognosis and extremely low risk for major cardiovascular events at follow up. These studies led to a few rapid rule out algorythms for MI according to undetectable HsTnI in first hours following admission. Purpose The aim of the study was to examine whether a maximal HsTnI under 5 ng/dl, in a hemodynamicaly stable patient, is sufficient to discharge a patient without further testing. Methods Retrospective analysis of patients admitted to the emergency depatment due to suspected myocardial infarction between February 2016 and December 2018. All patients had a HsTnI under 5 ng/dl and were either discharged home or admitted for further observation and testing. The collection of data was performed by the MDCLONE software from the electronic medical records in our medical center. Results Between February 2016 and December 2018, 10,936 patients were admitted to the emergency department due to chest pain or suspected MI. In 7925 (72%) the maximal HsTnI value was under 5 ng/dl. Group 1 included 6699 (85%) patients who did not undergo any further test and group 2 included 1226 (15%) who were admitted for further testing. Further testing included Coronary CT in 999 (81%) and Stress myocardial perfusion imaging (MPI) in 227 (19%). 11 patients underwent both tests. Out of the 999 patients examined with coronary CT, 114 (11%) needed further evaluation with coronary angiogiography and 41 required angioplasty and stening. 18 (7%) patients that were evaluated using stress MPI needed angio and 7 (3%) required stenting. Comparing the group 1 and 2, patients who went through further testing were more likely to be older, with higher prevalence of diabetes, hypertenstion, smoking history and after CABG in the past. Group 1 had 0.07%, 0.16% and 0.33% all cause mortality in 30, 90 and 360 days respectivly. Group 2 had no mortality in 30 and 90 days, and 0.25% all cause mortality in 360 days. No statistical significance was reached in all time points. There was no difference in re-admissions in the first 90 days after discharge between the groups. Conclusions Based on our data, patients admitted to the emergency department due to suspected myocardial infarction and known cardiovascular risk factors but with HsTnI under the 5 ng/dl, the use of rapid rule out algorithms may be questionable. Acknowledgement/Funding None
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Marcusohn et al. (2019) conducted a cohort in Suspected myocardial infarction (n=7,925). Discharge without further testing vs. Admission for further testing was evaluated on All-cause mortality at 360 days (p=NS). Discharging patients with suspected MI and HsTnI <5 ng/dl without further testing resulted in similar 360-day all-cause mortality compared to further testing (0.33% vs 0.25%, NS).
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