Key result
Point-of-care hsTnI reduced turnaround times (11 vs 87 min) with no excess 4-month adverse events after discharge (1.4% vs 1.2%), despite lower early AMI sensitivity than lab hsTnI (72.1% vs 91.5%).
Why the study?
Point-of-care tests reduce result turnaround times, but until recently there was a lack of assays fulfilling high-sensitivity criteria. Whether a newly introduced point-of-care high-sensitivity troponin I is a viable option for an Emergency Department chest pain pathway needed to be ascertained.
Does the availability and use of a point of care high sensitivity troponin I (POC-hsTnI) assay in an Emergency Department chest pain pathway reduce turnaround times without increasing 4-month adverse events (cardiac death or AMI) in patients presenting with undifferentiated chest pain?
Observational (n=688)
No
Does the availability and use of a point of care high sensitivity troponin I (POC-hsTnI) assay in an Emergency Department chest pain pathway reduce turnaround times without increasing 4-month adverse events (cardiac death or AMI) in patients presenting with undifferentiated chest pain?
Answers are grounded in this paper and cite their sources.
Implementing a point-of-care high-sensitivity troponin I assay within an Emergency Department chest pain risk stratification pathway substantially reduces result turnaround times (11 vs 87 minutes) and facilitates in-visit serial testing without increasing 4-month cardiac death or AMI rates, despite lower initial sensitivity on presentation.
Background In 2012 in a hospital, New Zealand, a chest pain pathway was instituted for the use in patients presenting to the Emergency Department (ED) with undifferentiated chest pain. This reduced hospital admissions and ED length of stay (LOS) without adversely affecting outcomes. The pathway consists of risk stratification combined with ECG and troponin testing. The pathway suggests, but does not enforce, that low risk patients can be discharged after a single troponin, intermediate risk patients are for serial troponins (which can be done in ED or the next day in the community), with further testing if appropriate, and high risk patients are reviewed by Cardiology or General medicine. In August 2023, Siemens point of care high sensitivity troponin I (POC-hsTnI) was introduced for the use in ED, although Beckman laboratory troponin I (Lab–hsTnI) is still available. A POC test reduces result turnaround times but until recently there has been a lack of POC assays fulfilling criteria for "high sensitivity". Purpose To ascertain whether the availability of a POC-hsTnI in the ED is a viable option for use in the chest pain pathway Methods A 1 month "snap shot" of all consecutive patients presenting to the ED with chest pain was undertaken and the patients followed for adverse events using electronic notes review. October 2023 was selected for the post POC-hsTnI period and compared with April 2022. Results There were 688 patients presenting to ED with undifferentiated chest pain during October 2023 with a type 1 acute myocardial infarction (AMI) rate of 80 (11.6%), median age 58 (41-72), female 335 (48.7%). POC-hsTnI was used in isolation in 377 (54.8%), in conjunction with Lab-hsTnI in 218 (31.7%) and Lab-hsTnI was used alone in 93 (13.5%). The median turnaround time for POC-hsTnI was 11 minutes (10-11) compared with Lab-hsTnI 87 minutes (61-129). The POC-hsTnI was less sensitive for AMI than the Lab-hsTnI on presentation using the upper reference limit, 72.1% (60.6-81.6) versus 91.5% (83.0-96.4). However, when used with risk stratification, there were no excess adverse events (cardiac death or AMI) at 4 months in patients discharged with a diagnosis of non-cardiac chest pain – 7 (1.4%) (n=495) versus 5 (1.2%), (n=424) in 2022. Median LOS in the ED was 4.4 hours (2.9-6.2) versus 4.0h (3.0-5.9) in 2022. However, a higher proportion of patients had a second cTn: 414 (60.2%) versus 309 (48.4%) and a lower proportion had their second troponin the next day in the community, 28 (6.7%) versus 56 (18.1%). Conclusion The use of a POC-hsTnI is a practical solution to reduce turnaround times for troponin results and has the potential to reduce LOS or allow serial troponins to be measured in a timely manner during their ED visit, obviating the need for a next day community troponin. Whilst POC-hsTnI has a lower early sensitivity for AMI, the use of POC-hsTnI as part of a pathway does not adversely affect outcomes.
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Aldous et al. (2024) conducted an observational in Undifferentiated chest pain (n=688). Siemens point of care high sensitivity troponin I (POC-hsTnI) vs. Beckman laboratory troponin I (Lab-hsTnI) / April 2022 cohort was evaluated on Adverse events (cardiac death or acute myocardial infarction) at 4 months in patients discharged with non-cardiac chest pain. Point-of-care hsTnI reduced turnaround times (11 vs 87 min) with no excess 4-month adverse events after discharge (1.4% vs 1.2%), despite lower early AMI sensitivity than lab hsTnI (72.1% vs 91.5%).
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