A rapid rule-out strategy based on high sensitive troponin and HEART score implemented in clinical routine is safe and reduces admission to hospital

Background: A one-hour algorithm with high sensitive troponin and HEART score are helpful for early rule-out and rule-in in chest pain patients. However, studies evaluating the impact of a combination of these methods in clinical practice are lacking. Purpose: The aim was to determine whether this strategy reduces admission rate and is safe. Methods: This was a prospective multicenter (6 centers) study in two phases, before (phase 1 2013-2014) and after (phase 2 2015-2016) introducing a new diagnostic strategy, including high sensitive troponin (troponin T (Hs-TnT) or troponin I (Hs-TnI)) at 0h and 1h, and applying the HEART score. If (1) troponin 0h was ≤ upper limit of normal, (2) delta-value at 1h was <3 ng/L (Hs-TnT) or <6 ng/L (Hs-TnI) and (3) HEART score was <4, acute coronary syndrome could be considered highly unlikely. All patients were followed for 30 days and events were adjudicated. Results: A total of 1233 patients were included. The two study cohorts were similar with regard to age (median: 64 vs. 63), proportion of most comorbidities and characteristics at presentation. The time from onset of symptoms to presentation (2.8 vs. 3.0 h) was also similar. The admission rate decreased from 59% in phase 1 to 33% in phase 2 (p<0.001). After adjusting for differences in baseline characteristics, the admission rate was still substantially lower in phase 2 (OR, 95% CI; 0.33, 0.25-0.42). For patients discharged from the ED, there were no differences regarding death, myocardial infarction (MI), new ED presentation or new admissions. For patients admitted to hospital, there were no differences regarding presence of MI or time to discharge. Conclusions: For the first time, we demonstrate that an introduction of a diagnostic strategy based on early serial measurements of high sensitive troponin and HEART score in clinical practice results in a substantially lower admission rate with no disadvantage for patients not admitted to hospital (Table Presented).