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Emerg Med Australas. 2018 Aug;30(4):486-493. doi: 10.1111/1742-6723.12919. Epub 2018 Jan 8.

Rapid and safe discharge from the emergency department: A single troponin to exclude acute myocardial infarction.

Author information

1
Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.
2
Clinical Biochemistry Unit, The Alfred Hospital, Melbourne, Victoria, Australia.
3
Central Clinical School, Monash University, Melbourne, Victoria, Australia.
4
Cardiology Department, The Alfred Hospital, Melbourne, Victoria, Australia.
5
Cardiology Department, Western Health, Melbourne, Victoria, Australia.
6
Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.
7
National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia.
8
Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.

Abstract

OBJECTIVE:

To determine variables that could facilitate safe discharge from the ED following a single high-sensitivity troponin I (HsTnI) result to exclude acute myocardial infarction (AMI).

METHODS:

A retrospective cohort study was performed at a tertiary hospital of all patients that had serial HsTnI performed within 12 h of arrival to the ED over a 3 year period. The primary exposure variable of interest was a very low troponin initial result (HsTnI <5 ng/L). Medical record review and risk stratification score calculations were undertaken for all patients with the exposure variable of interest and an abnormal second troponin measurement (HsTnI ≥16 ng/L in women and HsTnI ≥26 ng/L in men).

RESULTS:

There were 11 970 patients who presented between 1 July 2013 and 30 June 2016 that had serial HsTnI measurements performed. Of these, 4172 (34.9%) patients had an initial HsTnI measurement <5 ng/L. Of the patients with an initial HsTnI <5 ng/L that met inclusion criteria, 56 (1.3%) had a second troponin result above the 99th percentile and 32 (0.8%) cases of non-ST elevation myocardial infarction were diagnosed as well as 15 (0.4%) cases of ST elevation myocardial infarction. There were 44 (93.6%) of all AMI cases that met criteria for high-risk presentations under the National Heart Foundation of Australia guidelines. The negative predictive value of an initial HsTnI <5 ng/L to exclude AMI was 98.9% (95% confidence interval 98.5-99.1).

CONCLUSIONS:

This supports the utilisation of a rapid rule out strategy to exclude AMI for patients that have an initial HsTnI measurement <5 ng/L in conjunction with a robust risk assessment.

KEYWORDS:

emergency service; hospital; myocardial infarction; non-ST elevated myocardial infarction; risk assessment; troponin I

PMID:
29316329
DOI:
10.1111/1742-6723.12919
[Indexed for MEDLINE]

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