Having read the three papers published around the RATPAC Trial (1,2,3), I have come to the conclusion there has been a major miscarriage of justice. That miscarriage of justice relates to diagnostic equipment used in the standard treatment protocols for the hospitals involved in the RATPAC Trial (Beckman Access, Centaur CP and Roche E170). Point of Care Testing (POCT) was not convincingly vindicated in this trial but the other equipment and methods were deemed by association of the data to be inadequate. A cursory examination of the papers clearly shows : 1. The main reason for the improvement in patient discharge was the decision to change the time interval for testing cardiac markers from 12 hours (or 6 hours in one case) to 90 minutes. 2. The sensitivity of the equipment used for Troponin under the standard protocol was as good as the method used in the POCT protocol (Siemens Stratus) 3. Both POCT and Standard Care Equipment would have required a centrifuged sample so pre-analytical delay should have been the same. 4. The variability of results between sites was more about ED processes than the POCT protocol. Therefore simply using the equipment used in the standard care setting for the 90 minute protocol would, in my opinion, have given basically the same outcomes. Point of care analysis per se was not a major player in this trial. This was all about changing timeframes and processes. I therefore find the conclusion that "Point of care testing panel assessment increases successful discharge home and reduces median length of stay........" misleading. The use of troponin alone by the standard protocol methods has been evaluated elsewhere (4,5) and with great success. It is therefore not surprising that the economic assessment of the RATPAC trial found point of care testing to be expensive. It has been found in this case to be unnecessary. What was also unnecessary was the standard care guideline of a 12 hour delay, though that was the recommendation and guideline at the time, and the contributors were right to be using it. It is an old guideline and troponin methods have improved so much as to make that interval redundant. What this paper highlights is not that POCT can improve turnaround in ED but that protocols need to be kept up to date with technological change and clinical research. This is easier said than done given the complexity of committees looking after guidelines and the conservative nature of change in a clinical setting. I therefore declare a mistrial and absolve the Beckman Access, Roche E170 and Centaur CP of any inference of inadequacy and everyone else of any criticism for what is still a well planned, executed and valuable trial in showing that processes and procedures are more important than equipment and that variations are more about people and the conditions they work under. REFERENCES: 1.Goodacre, SW et al "The Randomised Assessment of Treatment using Panel Assay of Cardiac Markers (RATPAC) trial : a randomised controlled trial of point-of-care cardiac markers in the emergency department" Heart 2011 97:190-196; doi:10.1136/hrt.2010.203166 2. Fitzgerald, P et al "Cost-Effectiveness of Point-of-care Biomarker Assessment for Suspected Myocardial Infarction : The Randomised Assessment of Treatment Panel Assay of Cardiac Markers (RATPAC) Trial" Acad Emerg Med 2011;18(5):488-495 3. Bradburn, M et al "Interhospital Variation in the RATPAC trial (Randomised Assessment of Treatment Panel Assay of Cardiac Markers). Emerg Med J 2011; May 26 doi: 10.1136/emj.2010.108522 4. Keller, T et al "Sensitive Troponin I in Early Diagnosis of Acute Myocardial Infarction" NEJM 2009;361:868-877 5. Reichlin, T et al "Early Diagnosis of Myocardial Infarction with Sensitive Cardiac Troponin Assays" NEJM 2009;361:858-867

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