Written by Jason Lesnick
Spoon Feed
This RCT of U.S. patients being evaluated for acute MI using a 0/1 hour hs-cTnI protocol, compared to standard care with a 0/3 hour hs-cTnI protocol, didn’t find a difference in the percentage of patients discharged from the ED nor in the rates of 30 day death or MI.
Are high sensitivity troponins helping in U.S. EDs?
This study, the RACE-IT trial, was a stepped-wedge, randomized trial of 32,609 consecutive patients being evaluated for ACS in Michigan across 9 EDs from July 2020 to April 2021.
It measured the proportion of patients safely discharged from the ED without 30-day death or MI using either a 0/1 hour accelerated protocol or a 0/3 hour standard care protocol. The secondary outcomes included 30 day death, MI, or coronary revascularization in discharged patients.
The protocol utilized is below.
The authors found the accelerated protocol (57.8% discharged) was not superior to standard care (59.5%) with regard to the proportion of patients discharged. The accelerated protocol and standard care groups both had rates of death or MI at 30 days of 0.4%.
How will this change my practice?
It won’t immediately change my practice, as my institution is switching to a hs-cTn pathway based on High STEACS. I am optimistic about the future of implementing hs-cTn pathways from an efficiency standpoint, because this trial found 85% of the 10,445 patients had MI excluded after the first troponin.
Source
Rapid Acute Coronary Syndrome Evaluation Over One Hour With High-Sensitivity Cardiac Troponin I: A United States-Based Stepped-Wedge, Randomized Trial. Ann Emerg Med. 2024 Jun 15:S0196-0644(24)00235-X. doi: 10.1016/j.annemergmed.2024.04.024. Epub ahead of print. PMID: 38888531.
We’re using a protocol based on High STEACS now. The three hour rule out seems unnecessary. I’m curious to see what yours looks like.