Patients with chest pain contribute substantially to emergency department attendances,
lengthy hospital stay, and inpatient admissions. A reliable, reproducible, and fast
process to identify patients presenting with chest pain who have a low short-term
risk of a major adverse cardiac event is needed to facilitate early discharge. We
aimed to prospectively validate the safety of a predefined 2-h accelerated diagnostic
protocol (ADP) to assess patients presenting to the emergency department with chest
pain symptoms suggestive of acute coronary syndrome.
This observational study was undertaken in 14 emergency departments in nine countries
in the Asia-Pacific region, in patients aged 18 years and older with at least 5 min
of chest pain. The ADP included use of a structured pre-test probability scoring method
(Thrombolysis in Myocardial Infarction [TIMI] score), electrocardiograph, and point-of-care
biomarker panel of troponin, creatine kinase MB, and myoglobin. The primary endpoint
was major adverse cardiac events within 30 days after initial presentation (including
initial hospital attendance). This trial is registered with the Australia-New Zealand
Clinical Trials Registry, number ACTRN12609000283279.
3582 consecutive patients were recruited and completed 30-day follow-up. 421 (11.8%)
patients had a major adverse cardiac event. The ADP classified 352 (9.8%) patients
as low risk and potentially suitable for early discharge. A major adverse cardiac
event occurred in three (0.9%) of these patients, giving the ADP a sensitivity of
99.3% (95% CI 97.9-99.8), a negative predictive value of 99.1% (97.3-99.8), and a
specificity of 11.0% (10.0-12.2).
This novel ADP identifies patients at very low risk of a short-term major adverse
cardiac event who might be suitable for early discharge. Such an approach could be
used to decrease the overall observation periods and admissions for chest pain. The
components needed for the implementation of this strategy are widely available. The
ADP has the potential to affect health-service delivery worldwide.
Alere Medical (all countries), Queensland Emergency Medicine Research Foundation and
National Health and Medical Research Council (Australia), Christchurch Cardio-Endocrine
Research Group (New Zealand), Medquest Jaya Global (Indonesia), Science International
(Hong Kong), Bio Laboratories Pte (Singapore), National Heart Foundation of New Zealand,
and Progressive Group (Taiwan).
Copyright © 2011 Elsevier Ltd. All rights reserved.