High Sensitivity cTnT Rules Out Cardiac Insufficiency Trial (TACIT) (TACIT)

The purpose of this study is to better understand myocardial injury in AHF. Secondary analyses demonstrate the prognostic significance of troponin release. The absence of such release has been associated with less risk. Whether measurement of high sensitivity TnT may enable emergency physicians to better risk stratify acute heart failure patients remains to be determined. This study will help us to better understand the prognostic value of absent or low hsTnT values in the emergency department setting. In addition, we will also test the STRATIFY decision rule; a risk score.

Study Overview

• Status: Completed
• Conditions: Heart Failure
• Intervention / Treatment: Other: hsTnT level

Detailed Description

Hospitalization for acute heart failure (AHF) results in a high rate of post-discharge mortality and re-admissions, as well as high financial costs. Reducing 30-day re-admissions after AHF hospitalization is a major national quality goal intended to both improve patient outcomes and reduce costs.

Approximately 85% of emergency department (ED) patients with AHF are hospitalized, and 800,000 of the 1,000,000 hospitalizations for HF originate from the ED, highlighting the critical role of the ED. Even a single digit percentage (i.e. 5%) decrease in the number of AHF admissions would equate to an estimated 40,000 fewer hospitalizations.

Why are so many AHF patients hospitalized? AHF patients have a high post-discharge event rate. Emergency physicians have a low risk tolerance. When both are combined, most patients are admitted. The absence of risk scores for the ED setting compounds the problem. Most risk scores were developed in the hospital. As hospitalization may affect the outcomes of patients, whether these risk scores apply to the ED setting is unknown. As a result, which patients are at lower risk in the ED has not been well-studied. Further, absence of high-risk features does not necessarily equal absolute low morbidity or mortality, though such patients are likely at lower risk. In the absence of a risk score, clinical judgment is a poor substitute and often fails to identify patients at high risk, such that those discharged from the ED may be at equal or greater risk for death than hospitalized patients. Thus, the difficulty of identifying low risk, combined with the inherent high morbidity and mortality of AHF, leads to a disproportionate number of hospitalizations.

Over a decade ago, the Agency for Healthcare Research and Policy Guidelines suggested that up to 50% of AHF patients were potential candidates for ED discharge or observation unit management. Furthermore, nearly half of all patients hospitalized for AHF present with lower-risk features such as high blood pressure (> 140mmHg) and a BNP < 1000 pg/mL. If low or lower risk ED patients with HF could be accurately identified, perhaps a greater proportion of patients with AHF could be safely discharged or observed briefly prior to discharge.

Study Rationale: With this pilot study, we will generate the necessary and sufficient pilot data to inform the design of a definitive trial to test whether identification of low risk acute heart failure (AHF) patients with negative serial high-sensitivity troponin T (hsTnT) in the ED may be safely discharged home or observed briefly in observation status.

• Study Type: Observational
• Enrollment (Actual): 500

Contacts and Locations

Study Locations

• United States
  • Indiana
    • Indianapolis, Indiana, United States, 46202
      • IU Health Methodist Hospital
    • Indianapolis, Indiana, United States, 46202
      • Eskenazi Health
  • Michigan
    • Detroit, Michigan, United States, 48201
      • Detroit Receiving Hospital
  • Ohio
    • Cincinnati, Ohio, United States, 45220
      • University of Cincinnati
  • Tennessee
    • Nashville, Tennessee, United States, 37235
      • Vanderbilt University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 21 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Patients who present to the Emergency Department (ED) with signs and symptoms of AHF

Description

Inclusion Criteria:

1. Age ≥21 years old
2. Patient diagnosed with acute heart failure (AHF) by the treating physician.
3. Patient has received IV loop diuretic or vasodilator therapy (by any route) for AHF
4. Provide informed written consent
5. SBP > 100mmHg

Exclusion Criteria:

1. Life expectancy ≤6 months
2. Shock of any kind or use or planned use of inotropes (dobutamine, dopamine, milrinone) or vasopressors. Any form of vasodilator is allowed.
3. Fever > 101.5
4. Presumed ACS as primary reason for presentation or ACS within 30 days. Patients with troponin release outside of ACS (Type 2 MI) may be included
5. AF with RVR > 130bpm at any time requiring medical intervention
6. History of transplant of any kind or VAD patient
7. ESRD requiring dialysis
8. Involved in any investigational trial (observational study where there is no intervention is allowed)
9. Currently under treatment for cancer of any kind
10. Alcohol or other substance abuse
11. Any patient whom the investigator deems would be difficult to obtain follow-up

Study Plan

How is the study designed?

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
A composite of all cause mortality and re-hospitalization, including ED re-visits	Have increased the follow up from 30 to 90 days. Will also analyze for 30 days	90 days

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Days alive and out of hospital	Will also analyze for 30 days	90 days
Cardiovascular specific re-hospitalization and ED revisits	Will also analyze for 30 days	90 days
Hierarchial Adverse Events Model (STRATIFY Risk Score)	Will also analyze for 30 days	90 days

Collaborators and Investigators

• Sponsor: Indiana University
• Collaborators: Wayne State University; Vanderbilt University; University of Cincinnati

Publications and helpful links

General Publications

• Pang PS, Fermann GJ, Hunter BR, Levy PD, Lane KA, Li X, Cole M, Collins SP. TACIT (High Sensitivity Troponin T Rules Out Acute Cardiac Insufficiency Trial). Circ Heart Fail. 2019 Jul;12(7):e005931. doi: 10.1161/CIRCHEARTFAILURE.119.005931. Epub 2019 Jul 10.

Study record dates

Study Major Dates

• Study Start (Actual): December 21, 2015
• Primary Completion (Actual): November 7, 2017
• Study Completion (Actual): May 31, 2018

Study Registration Dates

• First Submitted: October 28, 2015
• First Submitted That Met QC Criteria: October 28, 2015
• First Posted (Estimate): October 30, 2015

Study Record Updates

• Last Update Posted (Actual): June 4, 2018
• Last Update Submitted That Met QC Criteria: June 1, 2018
• Last Verified: June 1, 2018

More Information

Terms related to this study

• Keywords: Acute Heart Failure; Acute Cardiac Insufficiency
• Additional Relevant MeSH Terms: Heart Diseases; Cardiovascular Diseases; Heart Failure
• Other Study ID Numbers: INEMER-0001

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED