Using an early rule-out pathway with high-sensitivity cardiac troponin (hs-cTn) to risk stratify patients with suspected acute coronary syndrome (ACS) is both effective and safe for low- and intermediate-risk groups, according to a new secondary analysis of the HiSTORIC trial.¹ The pathway not only reduces the length of hospital stay but also increases safe discharge from the emergency department (ED).
This study was a secondary analysis of the High-Sensitivity Cardiac Troponin on Presentation to Rule Out Myocardial Infarction (HiSTORIC) trial, a stepped-wedge cluster-randomised controlled trial.² Researchers evaluated data from 31,492 consecutive patients (mean age 59 years, 45% women) who presented to the ED with suspected ACS.
Patients were stratified at presentation into low-risk (hs-cTn <5 ng/L) or intermediate-risk (hs-cTn 5 ng/L to the 99th percentile) groups. The primary effectiveness outcome was the length of hospital stay, while the primary safety outcome was the incidence of subsequent myocardial infarction (MI) or cardiac death at 1 year.
Of the total cohort, 17,299 patients (54.9%) were classified as low-risk and 14,193 (45.1%) as intermediate-risk. Following the implementation of the risk stratification pathway, the length of stay was significantly reduced in both groups. For low-risk patients, the stay decreased from 6.9 hours to 4.7 hours (a difference of 2.2 hours). For intermediate-risk patients, it fell from 15.8 hours to 11.0 hours (a difference of 4.8 hours; p<0.001 for both).
Discharge rates from the ED also increased significantly. In the low-risk group, discharges rose from 62% to 83% (adjusted OR: 3.31; 95% CI: 3.06–3.57). In the intermediate-risk group, discharges increased from 36% to 55% (adjusted OR: 2.06; 95% CI: 1.92–2.21).
Regarding safety, patients discharged from the ED after the pathway's implementation had a lower risk of MI or cardiac death at 1 year compared to the pre-implementation period (1.0% vs 1.5%; adjusted HR: 0.65; 95% CI: 0.50–0.86). This improved safety profile was observed in both the low-risk (0.3% vs 0.6%) and intermediate-risk (2.4% vs 3.4%) cohorts.
The findings demonstrate that risk stratification using hs-cTn is a valuable tool in the ED for managing patients with suspected ACS across both low- and intermediate-risk profiles. The strategy effectively reduces the burden on hospitals by shortening stays and enabling more patients to be discharged safely. The investigators concluded that, “Patients discharged from the emergency department were at lower risk of subsequent myocardial infarction or cardiac death at 1 year.”
References
1. Li Z, Doudesis D, Bularga A, et al. Safety of Using Risk Stratification Along With High-Sensitivity Cardiac Troponin in the Emergency Department: A Secondary Analysis. JACC. 2025 Nov, 86 (19) 1738–1748. https://doi.org/10.1016/j.jacc.2025.08.059
2. Anand A, Lee KK, Chapman AR, et al. High-sensitivity cardiac troponin on presentation to rule out myocardial infarction: a stepped-wedge cluster randomized controlled trial. Circulation. 2021;143:2214-2224. https://doi.org/10.1161/CIRCULATIONAHA.120.052380
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