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Early Discharge Using Single Cardiac Troponin and Copeptin Testing in Patients With Suspected Acute Coronary Syndrome (ACS): A Randomized, Controlled Clinical Process Study
Study Questions:
Compared to standard process with serial troponin measurements in low- to intermediate-risk patients with suspected acute coronary syndrome (ACS), how safe is an early discharge after rule-out of acute myocardial infarction (AMI) with a single combined testing of troponin and copeptin at presentation to the emergency department/chest pain unit?
Methods:
This was a multicenter, international, clinical process, randomized, controlled trial. Copeptin was measured from the same initial blood draw as the first troponin value after randomization. In the standard group, patients were managed according to the standard of care for the management of patients with suspected ACS. In the interventional group, further management was dependent on the copeptin level. If the result was negative, patients were discharged; if a positive result, management was similar to that in the standard group. All discharged patients had a follow-up cardiology appointment within 3 days of discharge. The primary outcome was the proportion of combined major adverse cardiac events (MACE) within 30 days.
Results:
A total of 902 patients were randomized to either the standard (n = 451) or the copeptin (n = 451) group. A total of 46 patients developed a MACE during the 30-day follow-up period. In intention-to-treat analysis, 5.17% of standard care patients experienced MACE (95% confidence interval [CI], 3.30-7.65%), compared to 5.19% in the copeptin group (95% CI, 3.32-7.69%).
Conclusions:
A strategy using negative troponin and negative copeptin at presentation may help identify low- to intermediate-risk patients who can be safely discharged into outpatient care after presenting with suspected ACS.
Perspective:
The strategy of combined copeptin-troponin testing to rule out AMI has been evaluated in multiple retrospective observational studies. This is the first randomized controlled trial to evaluate the safety of such a strategy. However, and as acknowledged by the authors, these results need to be confirmed in larger clinical trials or registries.
Keywords: Myocardial Infarction, Acute Coronary Syndrome, Standard of Care, Patient Discharge, Troponin
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