A stepped-wedge cluster-randomised trial screened 71,983 consecutive emergency presentations with suspected myocardial infarction and analysed 67,624, comparing implementation of the 0/1 hour high-sensitivity troponin pathway with the 0/3 hour pathway. Myocardial infarction was adjudicated in 8.7% of presentations.
On safety the pathway passed: death or new type 1 infarction at 30 days occurred in 1.2% under 0/3 hour and 1.1% under 0/1 hour, an adjusted odds ratio of 0.93 meeting the non-inferiority criterion at P=0.0004.
On the reason most departments adopt it, the pathway failed completely. Median emergency department stay was 309 minutes under 0/3 hour and 309 minutes under 0/1 hour — a ratio of adjusted median times of exactly 1.00. Not a modest gain, not a gain that faded: no difference whatsoever.
That is the useful finding. A faster rule-out assay only shortens a stay if the assay is what the patient is waiting for, and in a real department they are waiting for a bed, a review, a scan or a discharge decision. Adopting 0/1 hour remains defensible on safety and on freeing analyser capacity. Adopting it to improve flow is buying the wrong thing.
- Non-inferior on 30-day death or new infarction — the safety case holds
- Median length of stay was identical to the minute; the ratio was 1.00
- Stepped-wedge implementation, so this measures adopting the pathway, not the assay
- If flow is the goal, look at what follows the troponin rather than the troponin
- Nearly 68,000 presentations, so this null is a genuine absence rather than a small sample
The statistics, in plain English
A non-inferiority result answers a narrower question than a superiority one: it says the new pathway is not meaningfully worse, within a margin set in advance, and does not claim it is better. The length-of-stay finding is the stronger statement — a ratio of 1.00 with an interval from 0.97 to 1.02, across 67,624 presentations, is a precisely measured absence of effect rather than a failure to detect one.
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