IMPORTANCE: Patients with chest pain represent a high health care burden, but it may be possible to identify a patient group with a low short-term risk of adverse cardiac events who are suitable for early discharge. OBJECTIVE: To compare the effectiveness of a rapid diagnostic pathway with a standard-care diagnostic pathway for the assessment of patients with possible cardiac chest pain in a usual clinical practice setting. DESIGN, SETTING, AND PARTICIPANTS: A single-center, randomized parallel-group trial with blinded outcome assessments was conducted in an academic general and tertiary hospital. Participants included adults with acute chest pain consistent with acute coronary syndrome for whom the attending physician planned further observation and troponin testing. Patient recruitment occurred from October 11, 2010, to July 4, 2012, with a 30-day follow-up. INTERVENTIONS: An experimental pathway using an accelerated diagnostic protocol (Thrombolysis in Myocardial Infarction score, 0; electrocardiography; and 0- and 2-hour troponin tests) or a standard-care pathway (troponin test on arrival at hospital, prolonged observation, and a second troponin test 6-12 hours after onset of pain) serving as the control. MAIN OUTCOMES AND MEASURES: Discharge from the hospital within 6 hours without a major adverse cardiac event occurring within 30 days. RESULTS: Fifty-two of 270 patients in the experimental group were successfully discharged within 6 hours compared with 30 of 272 patients in the control group (19.3% vs 11.0%; odds ratio, 1.92; 95% CI, 1.18-3.13; P = .008). It required 20 hours to discharge the same proportion of patients from the control group as achieved in the experimental group within 6 hours. In the experimental group, 35 additional patients (12.9%) were classified as low risk but admitted to an inpatient ward for cardiac investigation. None of the 35 patients received a diagnosis of acute coronary syndrome after inpatient evaluation. CONCLUSIONS AND RELEVANCE: Using the accelerated diagnostic protocol in the experimental pathway almost doubled the proportion of patients with chest pain discharged early. Clinicians could discharge approximately 1 of 5 patients with chest pain to outpatient follow-up monitoring in less than 6 hours. This diagnostic strategy could be easily replicated in other centers because no extra resources are required. TRIAL REGISTRATION: anzctr.org.au Identifier: ACTRN12610000766011.
RCT Entities:
IMPORTANCE: Patients with chest pain represent a high health care burden, but it may be possible to identify a patient group with a low short-term risk of adverse cardiac events who are suitable for early discharge. OBJECTIVE: To compare the effectiveness of a rapid diagnostic pathway with a standard-care diagnostic pathway for the assessment of patients with possible cardiac chest pain in a usual clinical practice setting. DESIGN, SETTING, AND PARTICIPANTS: A single-center, randomized parallel-group trial with blinded outcome assessments was conducted in an academic general and tertiary hospital. Participants included adults with acute chest pain consistent with acute coronary syndrome for whom the attending physician planned further observation and troponin testing. Patient recruitment occurred from October 11, 2010, to July 4, 2012, with a 30-day follow-up. INTERVENTIONS: An experimental pathway using an accelerated diagnostic protocol (Thrombolysis in Myocardial Infarction score, 0; electrocardiography; and 0- and 2-hour troponin tests) or a standard-care pathway (troponin test on arrival at hospital, prolonged observation, and a second troponin test 6-12 hours after onset of pain) serving as the control. MAIN OUTCOMES AND MEASURES: Discharge from the hospital within 6 hours without a major adverse cardiac event occurring within 30 days. RESULTS: Fifty-two of 270 patients in the experimental group were successfully discharged within 6 hours compared with 30 of 272 patients in the control group (19.3% vs 11.0%; odds ratio, 1.92; 95% CI, 1.18-3.13; P = .008). It required 20 hours to discharge the same proportion of patients from the control group as achieved in the experimental group within 6 hours. In the experimental group, 35 additional patients (12.9%) were classified as low risk but admitted to an inpatient ward for cardiac investigation. None of the 35 patients received a diagnosis of acute coronary syndrome after inpatient evaluation. CONCLUSIONS AND RELEVANCE: Using the accelerated diagnostic protocol in the experimental pathway almost doubled the proportion of patients with chest pain discharged early. Clinicians could discharge approximately 1 of 5 patients with chest pain to outpatient follow-up monitoring in less than 6 hours. This diagnostic strategy could be easily replicated in other centers because no extra resources are required. TRIAL REGISTRATION: anzctr.org.au Identifier: ACTRN12610000766011.
Authors: Tobias Reichlin; Raphael Twerenbold; Karin Wildi; Maria Rubini Gimenez; Nathalie Bergsma; Philip Haaf; Sophie Druey; Christian Puelacher; Berit Moehring; Michael Freese; Claudia Stelzig; Lian Krivoshei; Petra Hillinger; Cedric Jäger; Thomas Herrmann; Philip Kreutzinger; Milos Radosavac; Zoraida Moreno Weidmann; Kateryna Pershyna; Ursina Honegger; Max Wagener; Thierry Vuillomenet; Isabel Campodarve; Roland Bingisser; Òscar Miró; Katharina Rentsch; Stefano Bassetti; Stefan Osswald; Christian Mueller Journal: CMAJ Date: 2015-04-13 Impact factor: 8.262
Authors: Simon A Mahler; Chadwick D Miller; Harold I Litt; Constantine A Gatsonis; Bradley S Snyder; Judd E Hollander Journal: Acad Emerg Med Date: 2015-03-24 Impact factor: 3.451
Authors: Brian B Ghoshhajra; Richard A P Takx; Pedro V Staziaki; Harshna Vadvala; Phillip Kim; Tomas G Neilan; Nandini M Meyersohn; Daniel Bittner; Sumbal A Janjua; Thomas Mayrhofer; Jeffrey L Greenwald; Quyhn A Truong; Suhny Abbara; David F M Brown; James L Januzzi; Sanjeev Francis; John T Nagurney; Udo Hoffmann Journal: Eur Radiol Date: 2016-11-24 Impact factor: 5.315
Authors: Andrea Fabbri; Cristina Bachetti; Filippo Ottani; Alice Morelli; Barbara Benazzi; Sergio Spiezia; Marco Cortigiani; Romolo Dorizzi; Allan S Jaffe; Marcello Galvani Journal: Intern Emerg Med Date: 2018-11-29 Impact factor: 3.397
Authors: Jason P Stopyra; Chadwick D Miller; Brian C Hiestand; Cedric W Lefebvre; Bret A Nicks; David M Cline; Kim L Askew; Robert F Riley; Gregory B Russell; Greg L Burke; David Herrington; James W Hoekstra; Simon A Mahler Journal: Crit Pathw Cardiol Date: 2016-06