Written by Jason Lesnick
Spoon Feed
This Australian study found patients who were eligible for rapid rule out based on a single high-sensitivity cardiac troponin I (hs-cTnI) ≤2 ng/L pathway had shorter hospital length of stay (LOS) and no increase in index or 30-day cardiac events.
1 trop, 2 people sharing a decision
This stepped-wedge cluster randomized trial asked whether a single hs-cTnI ≤2 ng/L (the limit of detection) plus shared decision-making safely reduced ED and hospital length of stay for suspected ACS.
The authors analyzed 9,944 adults across 4 Australian EDs who presented with chest pain for at least 2 hours prior to assessment and did not have an ischemic ECG.
The intervention group had reduced mean LOS by 3.6 hours (95%CI 2.5–4.6), increased safe discharge within 4 hours by 22.9% (95%CI 19.5–26.3), decreased ED LOS by 97 minutes (95%CI 79 to 115 minutes), decreased exercise stress testing by 7.8%, and showed no increase in index or 30-day cardiac events.
Notably, in this cohort of patients a single troponin ≤2 ng/L had sensitivity of 99.8% and negative predictive value of 99.9% for index events.
How will this change my practice?
High-sensitivity troponins are here to stay. However, it is unclear how much they are actually helping us. Some studies have shown using high-sensitivity troponin pathways can decrease LOS (we covered one here). The pathway a hospital system adopts massively influences how useful it is (i.e. 0/1, 0/2, 0/3, +/- HEART score) with regard to decreasing LOS. Most importantly, however, this study won’t change my practice anytime soon, because the FDA has not approved high-sensitivity troponins to report out the limit of detection (see here).
Source
The Limit of Detection in the Emergency Department Trial (LEGEND): A Stepped-Wedge Cluster Randomized Trial to Rule Out Acute Myocardial Infarction and Reduce Hospital Length of Stay for Patients Presenting to the Emergency Department. Ann Emerg Med. 2026 Apr;87(4):424-434. doi: 10.1016/j.annemergmed.2025.10.014. Epub 2025 Dec 16. PMID: 41405523.
