For millions of people who arrive at emergency departments each year with chest pain, how quickly clinicians can confidently rule in or rule out a heart attack has profound consequences — for outcomes, hospital throughput, and patient anxiety. A large international trial now provides rigorous evidence that the faster, one-hour troponin testing window is not only as safe as the longer three-hour standard but operationally superior.
The PRESC1SE-MI trial enrolled nearly 72,000 consecutive adult presentations across 19 hospitals in ten countries, making it one of the largest prospective evaluations of cardiac triage pathways to date. Using a stepped-wedge cluster-randomised design — in which hospitals sequentially transitioned from drawing high-sensitivity cardiac troponin at 0 and 3 hours to drawing at 0 and 1 hour — investigators tested both non-inferiority for safety and superiority for efficiency. The coprimary safety endpoint was a composite of all-cause mortality or new type 1 myocardial infarction within 30 days. The coprimary efficacy endpoint was emergency department length of stay. Non-inferiority was pre-specified at an odds ratio threshold of 1.3.
This finding carries meaningful clinical weight because the 0/1 h pathway is already embedded in European Society of Cardiology guidelines, yet adoption has lagged in many hospital systems — partly due to lingering concern that a shortened observation window might miss slow-rising troponin signals in certain infarct patterns. The trial's scale and pragmatic real-world design make it considerably more persuasive than earlier single-center observational validations. The stepped-wedge methodology also controls for secular trends within each institution, strengthening causal inference beyond what a simple before-after comparison would allow. Key limitations include the masked-endpoint rather than fully blinded design, and potential variability in troponin assay platforms across participating sites. Still, for health systems still operating 3-hour protocols, this evidence base now represents a strong, replication-supported rationale for transition — with downstream benefits for patient flow and resource allocation.