LEGEND Trial Shortens Emergency Department Stay With Troponin Strategy

Key Takeaways

• Among patients in the LEGEND cohort (presentation troponin ≤2 ng/L), the intervention was associated with shorter hospital length of stay than standard care.
• The strategy was also associated with a higher proportion safely discharged within 4 hours and less cardiac testing.
• No differences were reported in representations, index events, or 30-day events.

In the LEGEND trial, patients in the LEGEND cohort (presentation troponin ≤2 ng/L) had a mean hospital length of stay 3.6 hours shorter with the intervention than with standard care. The stepped-wedge cluster randomized controlled trial was conducted across four Australian emergency departments, and the 95% confidence interval for the difference was 2.5 to 4.6 hours. Investigators evaluated a rule-out pathway integrating high-sensitivity cardiac troponin assay concentrations with shared decision making. Short-term safety outcomes did not differ between study periods.

From August 2019 to July 2020, the trial enrolled 9,944 adults presenting with suspected acute coronary syndrome at four Australian emergency departments. Of these, 5,347 patients received standard care and 4,597 were treated during the intervention period. The LEGEND pathway was a rule-out strategy that integrated high-sensitivity cardiac troponin assay concentrations with shared decision making, and the LEGEND cohort was defined by presentation troponin concentrations of 2 ng/L or lower. Length of stay was the primary outcome, and secondary outcomes included discharge from hospital within 4 hours, cardiovascular tests, representations, index events, and 30-day events.

Beyond the shorter length of stay, the proportion of patients safely discharged within 4 hours increased by 22.9%, with a 95% confidence interval of 19.5% to 26.3%, and cardiac testing decreased by 7.8%, with a 95% confidence interval of 4.6% to 11.1%. Together, these findings showed shorter hospital length of stay with less cardiac testing during the intervention period.

No differences were reported in representations, index events, or 30-day events. The authors concluded that the strategy safely ruled out acute myocardial infarction while reducing hospital length of stay and cardiac testing and increasing discharge within 4 hours. The findings centered on shorter throughput measures, with no reported difference in short-term events.