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Given the frequency of presentations to the ED of patients with chest pain, there is a great need to triage patients and accurately identify truly low-risk patients who do not require prolonged observation and serial blood and ECG testing. The strategy outlined above seems a reasonable way to stratify these types of patients, but further study needs to validate this approach before it could become standard practice. Cost effectiveness of high-sensitivity troponin compared to conventional troponin among patients presenting with undifferentiated chest pain: This Australian study investigated the cost-effectiveness of high-sensitivity troponin T (hs-TnT) compared with conventional troponin T (c-TnT) in patients presenting with chest pain. 1937 patients were randomised to hs-TnT or c-TnT for routine management of ACS, and were followed -up for 12 months. The primary outcome measure was the number of cumulative combined outcomes of all-cause mortality and new or recurrent ACS avoided. Mean Australian Medicare costs were higher in the hs -TnT arm than the c-TnT arm (by $1285 per patient) but mean total adverse clinical outcomes avoided were also higher in the hs-TnT arm (by 0.012 per patient). This resulted in an incremental cost- effectiveness ratio (ICER) of $108,552 per adverse clinical outcome avoided. When the analysis was restricted to patients below the threshold of normal troponin testing (actual c-TnT levels <30 ng/L), the ICER was $49,030 per adverse clinical outcome avoided.
Estimation of hs-TnT is increasingly being used in Australia to diagnose or rule out ACS in patients who present with chest pain. Standard management dictates that troponin needs to be measured 6 hours after the onset of chest pain to rule out MI, so many patients have longer stays in the ED than may be necessary or are admitted for observation. This study shows that the costs of using hs-TnT are high when used in this way, although clinical events were decreased, so identification of low-risk patients who can be discharged early is becomingly increasingly important .
Effect of oral iron repletion on exercise capacity in patients with heart failure with reduced ejection fraction and iron deficiency: The IRONOUT HF trial investigated the effects of oral iron supplementation on exercise capacity in patients with heart failure with reduced ejection fraction (HFrEF) and iron deficiency. 225 patients with HFrEF (<40%) and iron deficiency were randomised in a double-blind design to receive oral iron polysaccharide (150mg twice daily) or placebo for 16 weeks. The primary end-point was a change in peak oxygen uptake (VO2) from baseline to week 16. The median baseline peak VO2 was 1196 mL/min in the oral iron group and 1167 mL/min in the placebo group. The change in peak VO 2 at 16 weeks did not significantly differ between groups (+23 mL/min in the iron group vs −2 mL/min in the placebo group; p=0.46). These findings do not support the use of oral iron supplementation in patients with HFrEF. : Replenishment of iron stores with intravenous infusion has been shown to improve symptoms and outcomes in patients with HFrEF even if they are not anaemic. Oral iron is cheaper, but is poorly absorbed and tolerated, so it is not surprising that in this study, 16 weeks of oral treatment did not change iron stores much and there was no improvement in objective measures of exercise capacity.