Development and validation of the <scp>E</scp>mergency <scp>D</scp>epartment <scp>A</scp>ssessment of <scp>C</scp>hest pain <scp>S</scp>core and 2 h accelerated diagnostic protocol

Than, Martin; Flaws, Dylan; Sanders, Sharon; Doust, Jenny; Glasziou, Paul; Kline, Jeffrey A.; Aldous, Sally; Troughton, Richard W.; Reid, C.; Parsonage, William; Frampton, Christopher; Greenslade, Jaimi; Deely, John; Hess, Erik P.; Sadiq, Amr Bin; Singleton, Rose; Shopland, Rosie; Vercoe, Laura; Woolhouse-Williams, Morgana; Ardagh, Michael; Bossuyt, Patrick; Bannister, Laura; Cullen, L.

doi:10.1111/1742-6723.12164

Cited by 206 publications

(224 citation statements)

References 37 publications

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“…[61][62][63][64][65][66][67][68][69][70][71][72][73][74][75][76] Although most of the research in this area is observational, there have been 2 single-center RCTs, and there has been widespread implementation of such strategies in Australasia. The Australian state of Queensland and the country of New Zealand, with combined populations of nearly 10 million people, now have fully adopted accelerated diagnostic pathways.…”

Section: Combining Troponin With Risk Scoring Systems For Acceleratedmentioning

confidence: 99%

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

2016

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ABSTRACT:It is well established that clinicians cannot use clinical judgment alone to determine whether an individual patient who presents to the emergency department has an acute coronary syndrome. The history and physical examination do not distinguish sufficiently between the many conditions that can cause acute chest pain syndromes. Cardiac risk factors do not have sufficient discriminatory ability in symptomatic patients presenting to the emergency department. Most patients with non-ST-segment-elevation myocardial infarction do not present with electrocardiographic evidence of active ischemia. The improvement in cardiac troponin assays, especially in conjunction with well-validated clinical decision algorithms, now enables the clinician to rapidly exclude myocardial infarction. In patients in whom unstable angina remains a concern or there is a desire to evaluate for underlying coronary artery disease, coronary computed tomography angiography can be used in the emergency department. Once a process that took ≥24 hours, computed tomography angiography now can rapidly exclude myocardial infarction and coronary artery disease in patients in the emergency department.A bout 20 million patients present with symptoms possibly suggestive of acute coronary syndrome (ACS) to emergency departments (ED) in North America and Europe each year.1-3 Patients with ACS and acute myocardial infarction (AMI) present with a wide variety of symptoms such as chest pain, shortness of breath, weakness, nausea, vomiting, and even fatigue, making the diagnosis difficult. Demographics, cardiac risk factors, chest pain characteristics, and physical examination can assist disposition decisions but are insufficient to identify who does and does not have an ACS.4-7 Some patients may have objective evidence of a clearcut diagnosis, but the majority do not. 8 The majority ultimately will be found not to have ACS, but symptoms caused by noncardiac and often benign disorders such as musculoskeletal pain, pleuritis, or gastroesophageal reflux make the rapid rule-out of ACS more difficult and result in huge medical expenses. Safe and early rule-out of ACS contributes to more efficient and high-value healthcare delivery. History And PHysicAl ExAminAtionClinical features, alone or in combination with an ECG, are poorly predictive for AMI (Table 1). 9,10 In addition, they have variable reliability. Features classically associated with a lower probability of AMI such as pleuritic, positional, and sharp chest pain have poor to fair interphysician reliability (κ=0.27-0.44), 11 whereas high-risk features (radiation to left arm, substernal location, and history of AMI) are more reliable (κ=0.74-0.89). 11Traditional cardiac risk factors, derived from population-based longitudinal cohort studies of asymptomatic patients, are poor predictors of risk for AMI or ACS in symptomatic patients in the ED. 6,7 Similarly, the physical examination seldom is useful for distinguishing patients with ACS from patients with noncardiac chest pain.Trials of medications, onc...

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Section: Combining Troponin With Risk Scoring Systems For Acceleratedmentioning

confidence: 99%

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

2016

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“…Goldman and Vancouver Chest Pain rule, include the same class of factors with different weightings and variation in the components that make up the history and risk factor scores in particular [9,[19][20][21]. EDACS also includes sex.…”

Section: Discussionmentioning

confidence: 99%

“…A second measurement of hs-cTn from a blood sample drawn two to four-hours after hospital attendance time-point may be useful. Whereas accelerated chest pain pathways incorporating presentation and 2h sampling can identify an increased proportion of low-risk patients [8,9] a presentation and 3h or 4h timeframe is still short enough so that patients could remain in the ED under the care of the original clinicians without transfer to another hospital area or handover to other staff.…”

Section: Introductionmentioning

confidence: 99%

The utility of presentation and 4-hour high sensitivity troponin I to rule-out acute myocardial infarction in the emergency department

Pickering

Young²,

George

et al. 2015

Clinical Biochemistry

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The utility of presentation and 4-hour high sensitivity troponin I to rule-out acute myocardial infarction in the emergency department, Clinical Biochemistry (2015Biochemistry ( ), doi: 10.1016Biochemistry ( /j.clinbiochem.2015 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.The utility of presentation and 4-hour high sensitivity troponin I to rule-out acute myocardial infarction in the emergency department. A C C E P T E D M A N U S C R I P T ACCEPTED MANUSCRIPT2 Abstract a) Objectives: International guidance recommends that early serial sampling of high sensitivity troponin be used to accurately identify acute myocardial infarction (AMI) in chest pain patients.The background evidence for this approach is limited. We evaluated whether on presentation and 4-hour high-sensitivity troponin I (hs-cTnI) could be used to accurately rule-out AMI.b) Design and Methods: hs-cTnI was measured on presentation and at 4-hours in adult patients attending an emergency department with possible acute coronary syndrome. We determined the sensitivity for AMI for at least one hs-cTnI above the 99th percentile for a healthy population or alone or in combination with new ischemic ECG changes. Both overall and sex-specific 99th percentiles were assessed.. Patients with negative tests were designated low-risk. d) Conclusion: Hs-cTnI >99th percentile thresholds measured on presentation and at 4-hours was not a safe strategy to rule-out AMI in this clinical setting irrespective of whether sex-specific 99th percentiles were used, or whether hs-cTnI was combined with ECG results.

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“…[3][4][5][6] The methodology and results of the ADAPT trial warrant similar interest. With the use of cTnI as the sole biomarker, the authors were able to achieve similar sensitivities as in the ASPECT trial ( …”

Section: Commentarymentioning

confidence: 99%

An accelerated diagnostic protocol for the early, safe discharge of low-risk chest pain patients

Altherwi

Grad

2015

CJEM

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Clinical QuestionCan an accelerated 2-hour diagnostic protocol using the cardiac troponin I (cTnI) measurement as the only biomarker be implemented to allow an earlier and safe discharge of low-risk chest pain patients?Article ChosenThan M, Cullen L, Aldous S, et al. 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial. J Am Coll Cardiol 2012;59(23):2091-8.ObjectiveTo determine whether an accelerated diagnostic protocol (ADP) for possible cardiac chest pain could identify low-risk patients suitable for early discharge using cTnI as the sole biomarker.

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Development and validation of the Emergency Department Assessment of Chest pain Score and 2 h accelerated diagnostic protocol

Cited by 206 publications

References 37 publications

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

The utility of presentation and 4-hour high sensitivity troponin I to rule-out acute myocardial infarction in the emergency department

An accelerated diagnostic protocol for the early, safe discharge of low-risk chest pain patients

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