Regular paper
Impact of troponin T determinations on hospital resource utilization and costs in the evaluation of patients with suspected myocardial ischemia

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Abstract

The evaluation and triage of patients with suspected myocardial ischemia in the emergency department remains challenging and costly. Previous studies of cardiac troponins have focused predominately on patients with chest pain and have not randomized patients to different diagnostic strategies. Eight hundred fifty-six patients with suspected myocardial ischemia were prospectively randomized to receive a standard evaluation, including serial electrocardiographic and creatine phosphokinase-MB determinations (controls) or a standard evaluation with the addition of serial troponin T determinations (troponin group). The primary end points were length of stay and hospital charges. Significant reductions in length of hospital stay were seen in troponin T patients both with (3.6 vs 4.7 days; p = 0.01) and without (1.2 vs 1.6 days; p = 0.03) acute coronary syndromes compared with controls. Total hospital charges were reduced in a similar fashion in troponin patients with and without acute coronary syndromes ($15,004 vs $19,202; p = 0.01, and $4,487 vs $6,187; p = 0.17, respectively) compared with controls. Troponin patients without acute coronary syndromes had fewer hospital admissions (25% vs 31%; p = 0.04), whereas troponin patients with acute coronary syndromes had shorter telemetry and coronary care unit lengths of stay (3.5 vs 4.5 days; p = 0.03) compared with controls. Thus, utilization of troponin T in a broad spectrum of emergency department patients with suspected myocardial ischemia improves hospital resource utilization and reduces costs.

Section snippets

Study population

The study protocol was approved by the Bridgeport Hospital Institutional Review Board. After informed consent was obtained from the patient, 10 ml of blood was collected within 20 minutes after arrival for cardiac markers. The sample size necessary to show a 20% reduction in resource utilization and costs with 90% power was calculated to be 776 patients based on financial data from our institution. The study was carried out on 891 patients who presented to the ED between September 1997 and

Results

Of the 891 patients randomized to the study, 856 patients met the inclusion criteria and comprised the study group. Thirty-five patients were excluded for the following reasons: end-stage renal disease (6 patients), presence of ST elevation on the admitting ECG (25 patients), or multiple cardioversions or defibrillations in the ED (4 patients). Control patients underwent a standard clinical and electrocardiographic evaluation with serial CK-MB determinations (447 patients), whereas TnT patients

Discussion

This study validates the recent acknowledgment of cardiac troponins as the new standard for detection of myocardial necrosis16, 17 in a broad spectrum of patients with suspected myocardial ischemia (even when CK-MB is considered the gold standard). Previous studies have focused mainly on high-risk patients presenting with chest pain to the ED,6, 7, 8 whereas fewer studies have focused on low-risk patients.9, 10 As approximately one third of patients with AMI do not have chest pain at

Acknowledgements

We would like to acknowledge the help of Michael Cordone and Mark Markarian in helping coordinate data management.

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This study was supported by a grant from Roche Diagnostics, Indianapolis, Indiana.

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