Safety and efficacy of the 0/1 h pathway for myocardial infarction in the emergency department: an international, pragmatic, stepped-wedge, cluster-randomised, controlled trial.
Jasper Boeddinghaus, Paolo Bima, Luca Crisanti et al.
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In 30 seconds
This international, pragmatic, stepped-wedge, cluster-randomised controlled trial compared implementation of the 0/1 h versus 0/3 h high-sensitivity troponin pathway in adults presenting to emergency departments with suspected myocardial infarction. Across 19 hospitals in ten countries, the 0/1 h pathway met the prespecified non-inferiority criterion for 30-day death or new type 1 myocardial infarction: events occurred in 1·1% versus 1·2% of presentations (adjusted odds ratio 0·93 [95% CI 0·77-1·13]). Median emergency department length of stay was 309 min in both groups, with no evidence of a reduction.
Key findings
- The 30-day composite of death or new type 1 myocardial infarction occurred in 341 (1·1%) presentations with the 0/1 h pathway and 454 (1·2%) with the 0/3 h pathway.
- The adjusted odds ratio for the safety outcome was 0·93 [95% CI 0·77-1·13]; the 0/1 h pathway met the prespecified non-inferiority criterion.
- Median emergency department length of stay was 309 min in both groups; the ratio of adjusted median times was 1·00 [95% CI 0·97-1·02] (two-sided p=0·65).
Why it matters
The findings support the safety of implementing the guideline-recommended 0/1 h pathway in hospitals previously using 0/3 h testing, but show that faster serial sampling alone did not improve emergency department length of stay. This distinction matters when assessing pathway performance: diagnostic timing and overall department throughput are separate outcomes.
What to keep in mind
The trial evaluated implementation in hospitals that had not yet adopted the 0/1 h strategy; its findings do not establish that the pathway alone will improve throughput in other settings.