BACKGROUND: High-sensitivity cardiac troponin I (hs-cTnI) plays a central role in the diagnosis and management of non-ST-elevation myocardial infarction (NSTEMI), including rule-out and rule-in strategies in the emergency department. Extending hs-cTnI testing to the prehospital setting could accelerate patient orientation and clinical decision-making, but the diagnostic performance of prehospital capillary hs-cTnI remains insufficiently studied. OBJECTIVE: The study aimed to evaluate the diagnostic performance of prehospital capillary hs-cTnI for the diagnosis of NSTEMI at hospital discharge. DESIGN: The study is a prospective multicenter diagnostic accuracy study with blinded index test results. SETTINGS AND PARTICIPANTS: Four French emergency medical service systems with 10 mobile intensive care units. Adult patients presenting with acute chest pain were included. INDEX TEST: Prehospital hs-cTnI measurement using a point-of-care device (Atellica VTLi) on capillary samples. Treating clinicians were blinded to hs-cTnI results. OUTCOME MEASURES AND ANALYSIS: The primary outcome was the diagnostic performance of capillary hs-cTnI for the diagnosis of NSTEMI at hospital discharge. Diagnostic performance was assessed using the area under the receiver operating characteristic curve with 95% confidence intervals (CIs). Clinically relevant thresholds were defined a priori based on predefined safety criteria. MAIN RESULTS: Among 659 patients included in the primary analysis, 71 (10.8%) had NSTEMI. Prehospital capillary hs-cTnI demonstrated good diagnostic performance [area under the curve (AUC) = 0.83, 95% CI = 0.78-0.88]. A rule-out threshold of <2.2 ng/L, evaluated according to prespecified performance criteria, identified 7.1% of patients, with a negative predictive value of 1.00 (95% CI = 0.92-1.00). A rule-in threshold of >43.6 ng/L identified 6.5% of patients, with a positive predictive value of 0.65 (95% CI = 0.51-0.79). In the predefined sensitivity analysis, venous hs-cTnI showed similar diagnostic performance (AUC = 0.84, 95% CI = 0.79-0.89). CONCLUSION: Prehospital capillary hs-cTnI showed good diagnostic performance for NSTEMI, although feasibility in routine practice was challenged by unavailable or uninterpretable measurements. Further external validation is warranted before implementation in prehospital diagnostic pathways.
Emergency departments (EDs) face rising demand and resource constraints. Cost-effectiveness analyses (CEAs) can inform resource allocation, but patient-level CEAs in emergency care remain methodologically heterogeneous. This review aimed to identify and describe patient-level CEAs in emergency care between 2000 and 2025, appraise their methodological quality, and explore temporal trends and evidence gaps. This systematic review was reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020. PubMed/MEDLINE, Web of Science, CENTRAL, and gray literature were searched for patient-level CEAs of clinical or organizational interventions across prehospital, ED, and postemergency settings. Data were synthesized narratively across key methodological domains. Methodological quality of the economic evaluations was assessed using the quality of health economic studies (QHES) instrument. Descriptive and exploratory analyses were performed. Forty-seven studies were identified, of which 96% were conducted in EDs. Infectious diseases and ED crowding were the most addressed topics, followed by cardiovascular conditions and trauma, although a broad range of issues was covered. Studies were mainly conducted in high-income countries and evaluated organizational or diagnostic interventions. Healthcare system or hospital perspectives and short time horizons predominated. QHES scores were moderate-to-high (mean: 80.0, SD: 9.2, range: 56–96), with substantial variability and only a weak exploratory temporal trend toward higher scores. Prehospital and postemergency settings were underrepresented. Patient-level CEAs in emergency medicine are increasing, with many studies achieving high QHES scores, but remain heterogeneous in scope and methods. This review highlights the range of interventions evaluated and the methodological features relevant to interpreting economic evidence in emergency care.
