Objective This study aimed to assess whether an initial high-sensitivity troponin (HsTnT) value of <3 ng/l or a negative repeat value (<14 ng/l) at 3 h, could be used in conjunction with a validated cardiac risk score (HEART) and a normal 12 lead ECG to risk-stratify, reassure and discharge patients with low-risk presentations.
Background Many A&E departments still rely on a 12-hour negative HsTnT result for reassurance. Recent publications have demonstrated that a HsTnT value of 3 ng/l at presentation has a high negative predictive value for ruling out acute coronary syndromes with a <1% chance of major adverse cardiac events (MACE) at 1 year documented in one study.
Methods In a retrospective cohort study we followed up all patients who presented to the A&E department with an initial negative HsTnT (value <14 ng/l) over a three week period. We calculated a validated cardiac risk score for chest pain presentations (HEART). This was compiled for each patient based on their age, cardiac risk factors and the nature of the chest pain recorded in A&E, as well as by reviewing the serial ECGs taken on that presentation. We reviewed each patient’s clinical records at three months and cross-referenced each form of electronic record to identify and review any subsequent cardiac admissions/investigations over that period.
Results Of 291 patients 121 (41.6%) were admitted. 2 (0.7%) patients in this group had a raised HsTnT at 12 h and were thus classed as NSTEMIs. Both of these had an abnormal ECG and a HEART score of >4 on arrival to A&E. Of the remaining 119 patients admitted, none (0%) had any MACE at 3 months. 15 of the 119 HsTnT-negative patients underwent inpatient cardiac investigation (angiogram/stress ECHO/exercise tolerance testing/CT coronary angiogram), all of which were negative for significant coronary artery disease.
Of the 170 (58.4%) patients discharged from A&E none (0%) have had any MACE at 3 months. 53 of these 170 (31.2%) patients were referred into the Rapid Access Chest Pain Clinic. Of these 53, 10 patients underwent a negative stress echo, 11 patients undertook a negative exercise test and the remainder were discharged following a re-evaluation of their history, risk factors and 12 lead ECG. All 53 have had no MACE at 3 months.
Conclusions All of the patients in this study who had a negative HsTnT value on arrival to A&E, a normal ECG and a low clinical risk score (HEART score <4) have had no MACE as of three months. Many patients underwent further investigation and all of the results were negative for significant coronary artery disease. The data supports the use these criteria in risk-stratifying, reassuring and discharging such patients in a timely manner. It has been used to develop a new chest pain pathway in our local centre. We plan to evaluate the patients through direct patient contact at 6 months to assess MACE rate and exclude loss to another centre.
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