Point-of-care troponin may be safe, cost-saving method to rule out NSTEACS
Point-of-care troponin measurement by ambulance paramedics to rule out non-ST-elevation ACS in low-risk patients may reduce health care costs with similar 30-day adverse event risk vs. a direct-to-ED strategy, researchers reported.
The results of the investigator-initiated ARCTICA randomized clinical trial were published in the European Heart Journal.
Data were derived from Camaro C, et al. Eur Heart J. 2023;doi:10.1093/eurheartj/ehad056/7031792.
“We were surprised that it was feasible to implement the strategy in a fast and effective way, with more than 100 ambulances and more than 500 individual paramedics that all needed to be trained and equipped with the point-of-care troponin tests and risk score,” Niels van Royen, MD, PhD, professor of cardiology and head of department at Radboud University Medical Center in Nijmegen, the Netherlands, told Healio. “These results are very encouraging but need to be replicated in larger studies, in different care systems and in other countries before it can be fully implemented. Ideally, via randomized trials like ARTICA, or as an alternative with very strict monitoring.”
The ARCTICA trial was conducted in five ambulance regions in the Netherlands and included 863 participants with suspected non-ST-elevation ACS (NSTEACS; mean age, 54 years; 57% women). Patients with HEAR score of 3 or less — including history, ECG, age and risk factors — were randomly assigned to pre-hospital rule-out NSTEACS with a point-of-care troponin measurement conducted by ambulance paramedics or direct transfer to ED.
The primary outcome was 30-day health care costs. The secondary safety outcome was defined as 30-day major adverse cardiac events including ACS, unplanned revascularization or all-cause death.
van Royen and colleagues observed that average health care costs were lower among patients assigned to the pre-hospital troponin measurement strategy compared with direct transfer to ED (1,349 euros vs. 1,960 euros), with an average cost savings of 611 euros (95% CI, 353-869; P < .001).
Incidence of the secondary safety outcome of 30-day major adverse CV events was comparable between the pre-hospital troponin and direct-to-ED groups (3.9% for pre-hospital troponin vs. 3.7% for direct to ED; P = .89), according to the study.
Among patients for whom NSTEACS was ruled out, incidence of major adverse CV events were low (0.5% for pre-hospital troponin vs. 1% for direct to ED), with the between-group difference slightly favoring pre-hospital troponin measurement (risk difference, 0.5%; 95% CI, 1.6 to –0.7; P = .41), researchers reported.
“In principle, these results are well generalizable. In the Dutch health system, ambulance workers are very well trained and equipped, which is a prerequisite,” van Royen told Healio. “The Netherlands are very densely populated and distances are in general short, therefore the benefit in less dense populated areas like the US could be even larger. Implementation of this strategy can alleviate pressure on emergency departments which have to deal with serious overcrowding in many regions of the world. This has become evident during crises like COVID-19 but is also a problem on a day-to-day basis in many countries.”
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