• Neil Beri, Nicholas A Marston, Lori B Daniels, Richard M Nowak, Donald Schreiber, Christian Mueller, Allan Jaffe, Deborah B Diercks, Nicholas Wettersten, Christopher DeFilippi, W Frank Peacock, Alexander T Limkakeng, Inder Anand, James McCord, Judd E Hollander, Alan H B Wu, Fred S Apple, John T Nagurney, Cecilia Berardi, Chad M Cannon, Paul Clopton, Sean-Xavier Neath, Robert H Christenson, Christopher Hogan, Gary Vilke, and Alan Maisel.
• Department of Internal Medicine, University of California, San Diego, La Jolla, CA, United States. Electronic address: neil.beri1@gmail.com.
• Am J Emerg Med. 2017 Feb 1; 35 (2): 274-280.

BackgroundCopeptin is a marker of endogenous stress including early myocardial infarction(MI) and has value in early rule out of MI when used with cardiac troponin I(cTnI).ObjectivesThe goal of this study was to demonstrate that patients with a normal electrocardiogram and cTnI<0.040μg/l and copeptin<14pmol/l at presentation and after 2 h may be candidates for early discharge with outpatient follow-up potentially including stress testing.MethodsThis study uses data from the CHOPIN trial which enrolled 2071 patients with acute chest pain. Of those, 475 patients with normal electrocardiogram and normal cTnI(<0.040μg/l) and copeptin<14pmol/l at presentation and after 2 h were considered "low risk" and selected for further analysis.ResultsNone of the 475 "low risk" patients were diagnosed with MI during the 180day follow-up period (including presentation). The negative predictive value of this strategy was 100% (95% confidence interval(CI):99.2%-100.0%). Furthermore no one died during follow up. 287 (60.4%) patients in the low risk group were hospitalized. In the "low risk" group, the only difference in outcomes (MI, death, revascularization, cardiac rehospitalization) was those hospitalized underwent revascularization more often (6.3%[95%CI:3.8%-9.7%] versus 0.5%[95%CI:0.0%-2.9%], p=.002). The hospitalized patients were tested significantly more via stress testing or angiogram (68.6%[95%CI:62.9%-74.0%] vs 22.9%[95%CI:17.1%-29.6%], p<.001). Those tested had less cardiac rehospitalizations during follow-up (1.7% vs 5.1%, p=.040).ConclusionsIn conclusion, patients with a normal electrocardiogram, troponin and copeptin at presentation and after 2 h are at low risk for MI and death over 180days. These low risk patients may be candidates for early outpatient testing and cardiology follow-up thereby reducing hospitalization.Copyright © 2016 Elsevier Inc. All rights reserved.

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