Key result
Stress CMR protocol safely clears ~80% of ED patients with abnormal hsTn without further testing.
Why the study?
Patients presenting to the ED with chest pain often have abnormal hsTn, but only about 5% have an acute coronary syndrome.
Does a clinical disposition protocol including stress CMR safely guide disposition in intermediate-risk ED patients with chest pain and abnormal hsTn?
Observational (n=50)
Does a clinical disposition protocol including stress CMR safely guide disposition in intermediate-risk ED patients with chest pain and abnormal hsTn?
A disposition protocol utilizing stress CMR is feasible and safe for intermediate-risk ED patients with abnormal hsTn, facilitating safe discharge in 80% of cases without adverse events.
Supports CMR-guided disposition in this cohort; hypothesis-generating and requires randomized trials before practice change.
BACKGROUND: Patients presenting to the emergency department (ED) with chest pain often have abnormal high-sensitivity troponin (hsTn). However, only about 5% have an acute coronary syndrome. We aimed to assess the safety, feasibility, and utility of a clinical disposition protocol, including outpatient observation with stress cardiovascular magnetic resonance (CMR) in intermediate-risk patients with abnormal hsTn of unclear etiology. METHODS: Patients with abnormal hsTn and modified HEART-score ≤6 underwent CMR to inform diagnosis, risk stratification, and ED disposition. Patients were followed at 30 and 90 days for all-cause mortality, readmission for myocardial infarction, and unplanned coronary revascularization. RESULTS: CMR was completed in 50 patients (64 years, 56% male) at a median of 23.2 h after presentation to the ED. CMR findings of coronary artery disease (CAD) were present in 19 (38%, 19/50) of patients, of which 13 had known CAD and 6 received a new diagnosis of CAD. In 12 (24%, 12/50) patients, cardiac noncoronary artery disease was diagnosed [cardiomyopathy (8), valvular disease (3), and myocarditis/pericarditis (1)], of which the majority (83%) (10/12) were new diagnoses. CMR was normal in 19 (38%, 19/50) patients. After CMR results were reported, the decision to admit was made in 10 (20%, 10/50) patients, while 40 (80%, 40/50) were discharged from the ED without further cardiac testing. Follow-up was completed in 96% (48/50) of patients, of which no patients experienced an adverse event. CONCLUSION: A disposition protocol with outpatient observation and stress CMR is feasible and useful for determining the etiology of myocardial injury and risk stratification in patients presenting to the ED with chest pain, abnormal hsTn, and intermediate risk.
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Cavalier et al. (2025) conducted an observational in Chest pain with abnormal high-sensitivity troponin (n=50). Clinical disposition protocol including outpatient observation with stress cardiovascular magnetic resonance (CMR) was evaluated on All-cause mortality, readmission for myocardial infarction, and unplanned coronary revascularization at 30 and 90 days. A disposition protocol using stress CMR for intermediate-risk ED patients with abnormal hsTn allowed 80% to be discharged without further testing, with 0 adverse events at 90-day follow-up.
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