title: Providing Rapid Out of Hospital Acute Cardiovascular Treatment 4 (PROACT-4).
abstract: BACKGROUND
  Whether prehospital point-of-care (POC) troponin further accelerates the time to diagnosis in patients with chest pain (CP) is unknown. We conducted a randomized trial of POC-Troponin testing in the ambulance.
  
  
  RESULTS
  Patients with chest pain presenting by ambulance were randomized to usual care (UC) or POC-Troponin; ST-elevation myocardial infarction patients or those with noncardiovascular symptoms were excluded. Pre-hospital high-sensitivity troponin was analyzed on a POC device and available to the paramedic and emergency department (ED) staff. The final diagnosis was centrally adjudicated. The primary endpoint was time from first medical contact to discharge from ED or admission to hospital. We randomized 601 patients in 19 months; 296 to UC and 305 to POC-Troponin. After ambulance arrival, the first troponin was available in 38 minutes in POC-Troponin and 139 minutes in UC. In POC-Troponin, the troponin was >0.01 ng/mL in 17.4% and >0.03 ng/mL in 9.8%. Patients spent a median of 9.0 hours from first medical contact to final disposition, and 165 (27.4%) were admitted to the hospital. The primary endpoint was shorter in patients randomized to POC-Troponin (median 8.8 hours [6.2-10.8] compared to UC (median 9.1 hours [6.7-11.2]; P=0.05). There was no difference in the secondary endpoint of repeat ED visits, hospitalizations, or death in the next 30 days.
  
  
  CONCLUSIONS
  In this broad population of patients with CP, ambulance POC-Troponin accelerated the time to final disposition. Enhanced and more cost-effective early ED discharge of the majority of patients with CP calling 911 is an unrealized opportunity.
  
  
  BACKGROUND
  URL: https://www.ClinicalTrials.gov/. Unique identifier: NCT01634425.
authors.affiliation: Canadian VIGOUR Center, University of Alberta, Edmonton, Alberta, Canada (J.A.E., R.C.W., Y.Z., P.W.A.) Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada (J.A.E., R.C.W., W.T.).
authors.forename: Justin A
authors.initials: JA
authors.lastname: Ezekowitz
authors.affiliation: Canadian VIGOUR Center, University of Alberta, Edmonton, Alberta, Canada (J.A.E., R.C.W., Y.Z., P.W.A.) Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada (J.A.E., R.C.W., W.T.).
authors.forename: Robert C
authors.initials: RC
authors.lastname: Welsh
authors.affiliation: Alberta Health Services, Edmonton, Alberta, Canada (D.W., D.K.).
authors.forename: Dale
authors.initials: D
authors.lastname: Weiss
authors.affiliation: Royal Alexandra Hospital, Edmonton, Alberta, Canada (M.C., N.B.).
authors.forename: Michael
authors.initials: M
authors.lastname: Chan
authors.affiliation: Misericordia Hospital, Edmonton, Alberta, Canada (W.K.).
authors.forename: William
authors.initials: W
authors.lastname: Keeble
authors.affiliation: Sturgeon Community Hospital & Health Center, Edmonton, Alberta, Canada (F.K.).
authors.forename: Fadi
authors.initials: F
authors.lastname: Khadour
authors.affiliation: Grey Nuns Community Hospital, Edmonton, Alberta, Canada (S.S.).
authors.forename: Sanjay
authors.initials: S
authors.lastname: Sharma
authors.affiliation: Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada (J.A.E., R.C.W., W.T.).
authors.forename: Wayne
authors.initials: W
authors.lastname: Tymchak
authors.affiliation: University of Alberta Hospital, Edmonton, Alberta, Canada (S.S.).
authors.forename: Sunil
authors.initials: S
authors.lastname: Sookram
authors.affiliation: Royal Alexandra Hospital, Edmonton, Alberta, Canada (M.C., N.B.).
authors.forename: Neil
authors.initials: N
authors.lastname: Brass
authors.affiliation: Alberta Health Services, Edmonton, Alberta, Canada (D.W., D.K.).
authors.forename: Darren
authors.initials: D
authors.lastname: Knapp
authors.affiliation: Alere Inc, San Diego, CA (T.L.K.).
authors.forename: Thomas L
authors.initials: TL
authors.lastname: Koshy
authors.affiliation: Canadian VIGOUR Center, University of Alberta, Edmonton, Alberta, Canada (J.A.E., R.C.W., Y.Z., P.W.A.).
authors.forename: Yinggan
authors.initials: Y
authors.lastname: Zheng
authors.affiliation: Canadian VIGOUR Center, University of Alberta, Edmonton, Alberta, Canada (J.A.E., R.C.W., Y.Z., P.W.A.).
authors.forename: Paul W
authors.initials: PW
authors.lastname: Armstrong
mesh_terms: D000368:Aged; D000552:Ambulances; D002318:Cardiovascular Diseases / Q000097:blood / Q000175:diagnosis; D002637:Chest Pain / Q000097:blood / Q000175:diagnosis*; D004632:Emergency Medical Services / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000097:blood / Q000175:diagnosis; D019095:Point-of-Care Systems; D011237:Predictive Value of Tests; D012680:Sensitivity and Specificity; D013997:Time Factors; D019210:Troponin I / Q000097:blood*
chemical_list: D019210:Troponin I
keywords: acute coronary syndromes; ambulance; chest pain; clinical trial; troponin