Safety of Using Risk Stratification along with High-Sensitivity Cardiac Troponin in the Emergency Department: A Secondary Analysis (JACC October 2025-2)-Article: Safety of Using Risk Stratification along with High-Sensitivity Cardiac Troponin in the Emergency Department: A Secondary Analysis

Article: Safety of Using Risk Stratification along with High-Sensitivity Cardiac Troponin in the Emergency Department: A Secondary Analysis

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This secondary analysis of the HiSTORIC trial evaluated the effectiveness and safety of applying risk stratification with high-sensitivity cardiac troponin I (hs-cTnI) assays in emergency department (ED) patients presenting with suspected acute coronary syndrome (ACS). The study encompassed 31,492 consecutive patients classified at presentation into low risk (troponin ≤5 ng/L) and intermediate risk (>5 ng/L up to 99th percentile). The primary effectiveness outcome was reduced hospital length of stay (LOS), and primary safety outcome was occurrence of myocardial infarction or cardiac death within one year.<br /><br />Results showed significant reductions in LOS following implementation of hs-cTnI risk stratification: from 6.9 to 4.7 hours in low-risk patients and from 15.8 to 11.0 hours in intermediate-risk patients. ED discharges increased markedly—from 62% to 83% in low-risk and from 36% to 55% in intermediate-risk groups. Notably, patients discharged after implementation had a significantly lower risk of myocardial infarction or cardiac death at 1 year (1.0% vs. 1.5%; adjusted hazard ratio [aHR] 0.65). This safety benefit held for both low-risk (0.3% vs. 0.6%; aHR 0.46) and intermediate-risk (2.4% vs. 3.4%; aHR 0.74) patients. Secondary safety outcomes, including cardiac death and hospital reattendance, were also lower in discharged patients post-implementation. These findings were consistent across sexes.<br /><br />The study concludes that risk stratification using hs-cTnI effectively reduces hospital LOS and increases safe ED discharges in both low- and intermediate-risk ACS patients. Importantly, discharging patients based on hs-cTnI risk stratification was associated with lower subsequent adverse cardiac events, indicating improved risk assessment compared to prior practices. These results support incorporation of hs-cTnI-based early rule-out pathways to optimize ED management of suspected ACS, balancing efficiency with patient safety. Limitations include evaluation of a single troponin assay and lack of post-discharge care data. Overall, implementing hs-cTnI risk stratification enhances clinical decision-making in suspected ACS, benefiting patients and healthcare systems by reducing unnecessary admissions without increasing adverse outcomes.

Keywords

high-sensitivity cardiac troponin I

hs-cTnI

acute coronary syndrome

ACS

emergency department

risk stratification

hospital length of stay

myocardial infarction

cardiac death