RAPID-CPU: a prospective study on implementation of the ESC 0/1-hour algorithm and safety of discharge after rule-out of myocardial infarction

Kiril M Stoyanov, Hauke Hund, Moritz Biener, Jochen Gandowitz, Christoph Riedle, Julia Löhr, Matthias Mueller-Hennessen, Mehrshad Vafaie, Hugo A Katus, Evangelos Giannitsis, Kiril M Stoyanov, Hauke Hund, Moritz Biener, Jochen Gandowitz, Christoph Riedle, Julia Löhr, Matthias Mueller-Hennessen, Mehrshad Vafaie, Hugo A Katus, Evangelos Giannitsis

Abstract

Background: Although the value of fast diagnostic protocols in suspected acute coronary syndrome has been validated, there is insufficient real world evidence including patients with lower pre-test probability, atypical symptoms and confounding comorbidities. The feasibility, efficacy and safety of European Society of Cardiology (ESC) 0/1 and 0/3-hour algorithms using high-sensitivity troponin T were evaluated in a consecutive cohort with suspected acute coronary syndrome.

Methods: During 12 months, 2525 eligible patients were enrolled. In a pre-implementation period of 6 months, the prevalence of protocols, disposition, lengths of emergency department stay and treatments were registered. Implementation of the 0/1-hour protocol was monitored for another 6 months. Primary endpoints comprised the change of diagnostic protocols and 30-day mortality after direct discharge from the emergency department.

Results: Use of the ESC 0/1-hour algorithm increased by 270% at the cost of the standard 0/3-hour protocol. After rule-out (1588 patients), 1309 patients (76.1%) were discharged directly from the emergency department, with an all-cause mortality of 0.08% at 30 days (one death due to lung cancer). Median lengths of stay were 2.9 (1.9-3.8) and 3.2 (2.7-4.4) hours using a single high-sensitivity troponin T below the limit of detection (5 ng/L) at presentation and the ESC 0/1-hour algorithm, respectively, as compared to 5.3 (4.7-6.5) hours using the ESC 0/3-hour rule-out protocol (P<0.001). Discharge rates increased from 53.9% to 62.8% (P<0.001), without excessive use of diagnostic resources within 30 days.

Conclusion: Implementation of the ESC 0/1-hour algorithm is feasible and safe, is associated with shorter emergency department stay than the ESC 0/3-hour protocol, and an increase in discharge rates.

Trial registration: ClinicalTrials.gov , Unique identifier: NCT03111862.

Keywords: Acute coronary syndrome; clinical protocols; high-sensitivity troponin; real world evidence.

Conflict of interest statement

Conflict of interest: MB reports grants and non-financial support from AstraZeneca, non-financial support from Thermo Fisher. MMH reports grants and speaker honoraria from Roche Diagnostics; grants and non-financial support from BRAHMS Thermo Scientific. HAK received honoraria for lecturers from Roche Diagnostics, AstraZeneca, Bayer Vital, Daiichi-Sankyo, and held a patent on cTnT that has expired. EG received honoraria for lectures from Roche Diagnostics, AstraZeneca, Bayer Vital, Daiichi-Sankyo, Eli Lilly Deutschland. He serves as a consultant for Roche Diagnostics, BRAHMS Thermo Fisher, Boehringer Ingelheim, and has received research funding from BRAHMS Thermo Fisher, Roche Diagnostics, Bayer Vital and Daiichi Sankyo. All other authors have no conflicts of interest to declare.

Figures

Figure 1.
Figure 1.
Standards for reporting diagnostic accuracy studies statement (STARD) patient inclusion flow diagram.
Figure 2.
Figure 2.
Kaplan–Meier estimates of 30-day mortality in patients with rule-out of acute myocardial infarction by hospital admission: discharged from emergency department (blue) and admitted to hospital (red).
Figure 3.
Figure 3.
Length of stay in the emergency department by protocol for rule-out of acute myocardial infarction.
Figure 4.
Figure 4.
Kaplan–Meier estimates of 30-day mortality by diagnostic rule classification: rule-out (blue), observational zone (orange) and rule-in (red).

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Source: PubMed

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