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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

Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.
Clinical Biochemistry Unit, The Alfred Hospital, Melbourne, Victoria, Australia.
Central Clinical School, Monash University, Melbourne, Victoria, Australia.
Cardiology Department, The Alfred Hospital, Melbourne, Victoria, Australia.
Cardiology Department, Western Health, Melbourne, Victoria, Australia.
Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.
National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia.
Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.



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).


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).


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).


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.


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

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