Novel two-biomarker strategy permits early ACS rule-out

In an era of tight resource utilization, patient throughput problems with ED backlogs, and judicious placement of higher-acuity patients into the hospital, a risk-stratification system for acute coronary syndrome (ACS) that would allow for early discharge from the ED with outpatient follow-up rather than the current practice of an extended ED workup for two troponins 6 hours apart or hospital admission, has the potential to radically change care processes.
Hospitals have developed observation units to address the need to provide less-intensive services in these clinical situations, but these units have faced significant patient concerns due to higher copays for services provided that are billed by outpatient codes.

Dr. Hiren Shah

This study, using the novel biomarker called copeptin in addition to troponin, has shown equivalent 30-day incidence of major cardiovascular events when the early-discharge strategy is compared to current practice. I would note, however, that this assay was utilized only in low- to intermediate-risk patients, and that clinical assessment of cardiovascular risk should always supersede this new assay in the discharge decision-making process. Of course, the challenges in the determination of risk and the variability in individual physician clinical risk-assessment approaches remain significant barriers no matter which assay system is used.

Future larger studies and those with a lower lost-to-follow-up rate than the current one will yield important results that may better evaluate the copeptin assay. If the results are similar in a more thorough study, the potential to change clinical practice for our ACS patients and to affect hospital resource utilization remains very significant.

Dr. Hiren Shah is an assistant professor of medicine in the Feinberg School of Medicine, Northwestern University, Chicago, and a medical director of the Medicine and Cardiac Telemetry Hospitalist Unit at Northwestern Memorial Hospital. He is on the advisory board of Hospitalist News.