Early discharge using single cardiac troponin and copeptin testing in patients with suspected acute coronary syndrome (ACS): a randomized, controlled clinical process study

TY - JOUR

T1 - Early discharge using single cardiac troponin and copeptin testing in patients with suspected acute coronary syndrome (ACS): a randomized, controlled clinical process study

AU - Möckel, Martin

AU - Searle, Julia

AU - Hamm, Christian

AU - Slagman, Anna

AU - Blankenberg, Stefan

AU - Huber, Kurt

AU - Katus, Hugo

AU - Liebetrau, Christoph

AU - Müller, Christian

AU - Muller, Reinhold

AU - Peitsmeyer, Philipp

AU - von Recum, Johannes

AU - Tajsic, Milos

AU - Vollert, Jörn O

AU - Giannitsis, Evangelos

N1 - © The Author 2014. Published by Oxford University Press on behalf of the European Society of Cardiology.

PY - 2015/2/7

Y1 - 2015/2/7

N2 - AIMS: This randomized controlled trial (RCT) evaluated whether a process with single combined testing of copeptin and troponin at admission in patients with low-to-intermediate risk and suspected acute coronary syndrome (ACS) does not lead to a higher proportion of major adverse cardiac events (MACE) than the current standard process (non-inferiority design).METHODS AND RESULTS: A total of 902 patients were randomly assigned to either standard care or the copeptin group where patients with negative troponin and copeptin values at admission were eligible for discharge after final clinical assessment. The proportion of MACE (death, survived sudden cardiac death, acute myocardial infarction (AMI), re-hospitalization for ACS, acute unplanned percutaneous coronary intervention, coronary artery bypass grafting, or documented life threatening arrhythmias) was assessed after 30 days. Intention to treat analysis showed a MACE proportion of 5.17% [95% confidence intervals (CI) 3.30-7.65%; 23/445] in the standard group and 5.19% (95% CI 3.32-7.69%; 23/443) in the copeptin group. In the per protocol analysis, the MACE proportion was 5.34% (95% CI 3.38-7.97%) in the standard group, and 3.01% (95% CI 1.51-5.33%) in the copeptin group. These results were also corroborated by sensitivity analyses. In the copeptin group, discharged copeptin negative patients had an event rate of 0.6% (2/362).CONCLUSION: After clinical work-up and single combined testing of troponin and copeptin to rule-out AMI, early discharge of low- to intermediate risk patients with suspected ACS seems to be safe and has the potential to shorten length of stay in the ED. However, our results need to be confirmed in larger clinical trials or registries, before a clinical directive can be propagated.

AB - AIMS: This randomized controlled trial (RCT) evaluated whether a process with single combined testing of copeptin and troponin at admission in patients with low-to-intermediate risk and suspected acute coronary syndrome (ACS) does not lead to a higher proportion of major adverse cardiac events (MACE) than the current standard process (non-inferiority design).METHODS AND RESULTS: A total of 902 patients were randomly assigned to either standard care or the copeptin group where patients with negative troponin and copeptin values at admission were eligible for discharge after final clinical assessment. The proportion of MACE (death, survived sudden cardiac death, acute myocardial infarction (AMI), re-hospitalization for ACS, acute unplanned percutaneous coronary intervention, coronary artery bypass grafting, or documented life threatening arrhythmias) was assessed after 30 days. Intention to treat analysis showed a MACE proportion of 5.17% [95% confidence intervals (CI) 3.30-7.65%; 23/445] in the standard group and 5.19% (95% CI 3.32-7.69%; 23/443) in the copeptin group. In the per protocol analysis, the MACE proportion was 5.34% (95% CI 3.38-7.97%) in the standard group, and 3.01% (95% CI 1.51-5.33%) in the copeptin group. These results were also corroborated by sensitivity analyses. In the copeptin group, discharged copeptin negative patients had an event rate of 0.6% (2/362).CONCLUSION: After clinical work-up and single combined testing of troponin and copeptin to rule-out AMI, early discharge of low- to intermediate risk patients with suspected ACS seems to be safe and has the potential to shorten length of stay in the ED. However, our results need to be confirmed in larger clinical trials or registries, before a clinical directive can be propagated.

KW - Acute Coronary Syndrome/diagnosis

KW - Arrhythmias, Cardiac

KW - Biomarkers/metabolism

KW - Coronary Artery Bypass

KW - Death, Sudden, Cardiac/etiology

KW - Early Diagnosis

KW - Female

KW - Glycopeptides/metabolism

KW - Humans

KW - Male

KW - Middle Aged

KW - Myocardial Infarction/etiology

KW - Patient Discharge

KW - Patient Readmission

KW - Percutaneous Coronary Intervention

KW - Treatment Outcome

KW - Troponin T/metabolism

U2 - 10.1093/eurheartj/ehu178

DO - 10.1093/eurheartj/ehu178

M3 - SCORING: Journal article

C2 - 24786301

VL - 36

SP - 369

EP - 376

JO - EUR HEART J

JF - EUR HEART J

SN - 0195-668X

IS - 6

ER -