Early discharge using single cardiac troponin and copeptin testing in patients with suspected acute coronary syndrome (ACS): a randomized, controlled clinical process study.
OBJECTIVE
This randomized controlled trial (RCT) evaluated whether a process with single combined testing of copeptin and troponin at admission in patients with low-to-intermediate risk and suspected acute coronary syndrome (ACS) does not lead to a higher proportion of major adverse cardiac events (MACE) than the current standard process (non-inferiority design).


RESULTS
A total of 902 patients were randomly assigned to either standard care or the copeptin group where patients with negative troponin and copeptin values at admission were eligible for discharge after final clinical assessment. The proportion of MACE (death, survived sudden cardiac death, acute myocardial infarction (AMI), re-hospitalization for ACS, acute unplanned percutaneous coronary intervention, coronary artery bypass grafting, or documented life threatening arrhythmias) was assessed after 30 days. Intention to treat analysis showed a MACE proportion of 5.17% [95% confidence intervals (CI) 3.30-7.65%; 23/445] in the standard group and 5.19% (95% CI 3.32-7.69%; 23/443) in the copeptin group. In the per protocol analysis, the MACE proportion was 5.34% (95% CI 3.38-7.97%) in the standard group, and 3.01% (95% CI 1.51-5.33%) in the copeptin group. These results were also corroborated by sensitivity analyses. In the copeptin group, discharged copeptin negative patients had an event rate of 0.6% (2/362).


CONCLUSIONS
After clinical work-up and single combined testing of troponin and copeptin to rule-out AMI, early discharge of low- to intermediate risk patients with suspected ACS seems to be safe and has the potential to shorten length of stay in the ED. However, our results need to be confirmed in larger clinical trials or registries, before a clinical directive can be propagated.
Division of Emergency Medicine and CPU, Department of Cardiology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-University Medicine Berlin, Augustenburger Platz 1, Berlin 13353, Germany martin.moeckel@charite.de.
Martin
M
Möckel
Division of Emergency Medicine and CPU, Department of Cardiology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-University Medicine Berlin, Augustenburger Platz 1, Berlin 13353, Germany.
Julia
J
Searle
Kerckhoff Heart and Thoraxcenter, Bad Nauheim, Germany Medical Clinic I, University Hospital Gießen, Gießen, Germany.
Christian
C
Hamm
Division of Emergency Medicine and CPU, Department of Cardiology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-University Medicine Berlin, Augustenburger Platz 1, Berlin 13353, Germany.
Anna
A
Slagman
Department of General and Interventional Cardiology, University Heart Centre Hamburg, Hamburg, Germany.
Stefan
S
Blankenberg
Department of Cardiology and Internal Emergency Medicine, Wilhelminenspital, Vienna, Austria.
Kurt
K
Huber
Department of Angiology, Cardiology and Pneumology, University Hospital Heidelberg, Germany.
Hugo
H
Katus
Kerckhoff Heart and Thoraxcenter, Bad Nauheim, Germany Medical Clinic I, University Hospital Gießen, Gießen, Germany.
Christoph
C
Liebetrau
Department of Cardiology, Universitätsspital Basel, Switzerland.
Christian
C
Müller
School of Public Health and Tropical Medicine, James Cook University, Townsville, Australia.
Reinhold
R
Muller
Department of General and Interventional Cardiology, University Heart Centre Hamburg, Hamburg, Germany.
Philipp
P
Peitsmeyer
Division of Emergency Medicine and CPU, Department of Cardiology, Campus Virchow-Klinikum and Campus Charité Mitte, Charité-University Medicine Berlin, Augustenburger Platz 1, Berlin 13353, Germany.
Johannes
J
von Recum
Department of Cardiology and Internal Emergency Medicine, Wilhelminenspital, Vienna, Austria.
Milos
M
Tajsic
Thermo Fisher Scientific, Clinical Diagnostics, B·R·A·H·M·S GmbH, Hennigsdorf, Germany.
Jörn O
JO
Vollert
Department of Angiology, Cardiology and Pneumology, University Hospital Heidelberg, Germany.
Evangelos
E
Giannitsis
D054058:Acute Coronary Syndrome / Q000175:diagnosis*; D001145:Arrhythmias, Cardiac; D015415:Biomarkers / Q000378:metabolism; D001026:Coronary Artery Bypass; D016757:Death, Sudden, Cardiac / Q000209:etiology; D042241:Early Diagnosis; D005260:Female; D006020:Glycopeptides / Q000378:metabolism*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology; D010351:Patient Discharge; D010359:Patient Readmission; D062645:Percutaneous Coronary Intervention; D016896:Treatment Outcome; D020107:Troponin T / Q000378:metabolism*
D015415:Biomarkers; D006020:Glycopeptides; D020107:Troponin T; C048197:copeptins
Acute coronary syndrome (ACS); Acute myocardial infarction (AMI); Copeptin; Randomized controlled trial (RCT); Rule-out