Written by Amanda Mathews
High-sensitivity cardiac troponin for risk stratification in both low- and intermediate-risk patients reduced length of stay and increased discharges from the ED for patients with suspected acute coronary syndrome. Also, risk of subsequent myocardial infarction or cardiac death at 1 year was lower.
High sensitivity is here to stay
This was a pre-specified secondary analysis of the HiSTORIC trial. Low risk was defined as troponin < 5 ng/L and presentation > 2 hours from symptom onset. Intermediate risk was defined as initial troponin between 5 ng/L and the sex-specific 99th percentile or presentation within 2 hours of symptom onset. Low-risk patients could be immediately discharged, but intermediate-risk patients had additional troponin testing 2 hours from the initial troponin and were discharged if concentrations were unchanged and less than the sex-specific 99th percentile.
The trial enrolled 31,492 consecutive patients. Of these, 54.9% were classified as low risk, and 45.1% were classified as intermediate risk. Low-risk patients were younger and had fewer comorbidities. Low-risk length of stay was reduced 2.2 hours, and ED discharge increased from 62% to 83%. Intermediate-risk length of stay was reduced 4.8 hours, and ED discharge increased from 36% to 55%. The proportion of low-risk patients requiring serial troponin measurement fell from 37% to 17%. The proportion of intermediate-risk patients requiring serial troponin was similar, but the median time between serial measurements was reduced from 509 to 215 minutes. Additionally, patients who were discharged from the ED had lower risk of subsequent myocardial infarction or cardiac death at 1 year after the implementation of risk stratification 1.5% vs. 1.0%.
How does this change my practice?
High-sensitivity troponin and accelerated evaluation and discharge pathways are being increasingly utilized. This trial adds to the body of evidence and supports the use of these pathways. As EDs continue to deal with the challenges of boarding, being able to quickly and safely work up and discharge patients with chest pain is invaluable.
Source
HiSTORIC Trial Investigators. Safety of Using Risk Stratification Along With High-Sensitivity Cardiac Troponin in the Emergency Department: A Secondary Analysis. J Am Coll Cardiol. 2025 Nov 11;86(19):1738-1748. doi: 10.1016/j.jacc.2025.08.059. PMID: 41193094.
