Jaimi H Greenslade1, Edward W Carlton2, Christopher Van Hise3, Elizabeth Cho3, Tracey Hawkins4, William A Parsonage5, Jillian Tate6, Jacobus Ungerer6, Louise Cullen5. 1. Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia; School of Medicine, The University of Queensland, Brisbane, Queensland, Australia. Electronic address: j.greenslade@uq.edu.au. 2. Emergency Department, South Meade Hospital, North Bristol National Health Service Trust, Bristol, United Kingdom. 3. School of Medicine, The University of Queensland, Brisbane, Queensland, Australia. 4. Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia. 5. Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia; School of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia. 6. Pathology Queensland, Herston, Queensland, Australia.
Abstract
STUDY OBJECTIVE: This diagnostic accuracy study describes the performance of 5 accelerated chest pain pathways, calculated with the new Beckman's Access high-sensitivity troponin I assay. METHODS: High-sensitivity troponin I was measured with presentation and 2-hour blood samples in 1,811 patients who presented to an emergency department (ED) in Australia. Patients were classified as being at low risk according to 5 rules: modified accelerated diagnostic protocol to assess patients with chest pain symptoms using troponin as the only biomarker (m-ADAPT), the Emergency Department Assessment of Chest Pain Score (EDACS) pathway, the History, ECG, Age, Risk Factors, and Troponin (HEART) pathway, the No Objective Testing Rule, and the new Vancouver Chest Pain Rule. Endpoints were 30-day acute myocardial infarction and acute coronary syndrome. Measures of diagnostic accuracy for each rule were calculated. RESULTS: Data included 96 patients (5.3%) with acute myocardial infarction and 139 (7.7%) with acute coronary syndrome. The new Vancouver Chest Pain Rule and No Objective Testing Rule had high sensitivity for acute myocardial infarction (100%; 95% confidence interval [CI] 96.2% to 100% for both) and acute coronary syndrome (98.6% [95% CI 94.9% to 99.8%] and 99.3% [95% CI 96.1% to 100%]). The m-ADAPT, EDACS, and HEART pathways also yielded high sensitivity for acute myocardial infarction (96.9% [95% CI 91.1% to 99.4%] for m-ADAPT and 97.9% [95% CI 92.7% to 99.7%] for EDACS and HEART), but lower sensitivity for acute coronary syndrome (≤95.0% for all). The m-ADAPT, EDACS, and HEART rules classified more patients as being at low risk (64.3%, 62.5%, and 49.8%, respectively) than the new Vancouver Chest Pain Rule and No Objective Testing Rule (28.2% and 34.5%, respectively). CONCLUSION: In this cohort with a low prevalence of acute myocardial infarction and acute coronary syndrome, using the Beckman's Access high-sensitivity troponin I assay with the new Vancouver Chest Pain Rule or No Objective Testing Rule enabled approximately one third of patients to be safely discharged after 2-hour risk stratification with no further testing. The EDACS, m-ADAPT, or HEART pathway enabled half of ED patients to be rapidly referred for objective testing.
STUDY OBJECTIVE: This diagnostic accuracy study describes the performance of 5 accelerated chest pain pathways, calculated with the new Beckman's Access high-sensitivity troponin I assay. METHODS: High-sensitivity troponin I was measured with presentation and 2-hour blood samples in 1,811 patients who presented to an emergency department (ED) in Australia. Patients were classified as being at low risk according to 5 rules: modified accelerated diagnostic protocol to assess patients with chest pain symptoms using troponin as the only biomarker (m-ADAPT), the Emergency Department Assessment of Chest Pain Score (EDACS) pathway, the History, ECG, Age, Risk Factors, and Troponin (HEART) pathway, the No Objective Testing Rule, and the new Vancouver Chest Pain Rule. Endpoints were 30-day acute myocardial infarction and acute coronary syndrome. Measures of diagnostic accuracy for each rule were calculated. RESULTS: Data included 96 patients (5.3%) with acute myocardial infarction and 139 (7.7%) with acute coronary syndrome. The new Vancouver Chest Pain Rule and No Objective Testing Rule had high sensitivity for acute myocardial infarction (100%; 95% confidence interval [CI] 96.2% to 100% for both) and acute coronary syndrome (98.6% [95% CI 94.9% to 99.8%] and 99.3% [95% CI 96.1% to 100%]). The m-ADAPT, EDACS, and HEART pathways also yielded high sensitivity for acute myocardial infarction (96.9% [95% CI 91.1% to 99.4%] for m-ADAPT and 97.9% [95% CI 92.7% to 99.7%] for EDACS and HEART), but lower sensitivity for acute coronary syndrome (≤95.0% for all). The m-ADAPT, EDACS, and HEART rules classified more patients as being at low risk (64.3%, 62.5%, and 49.8%, respectively) than the new Vancouver Chest Pain Rule and No Objective Testing Rule (28.2% and 34.5%, respectively). CONCLUSION: In this cohort with a low prevalence of acute myocardial infarction and acute coronary syndrome, using the Beckman's Access high-sensitivity troponin I assay with the new Vancouver Chest Pain Rule or No Objective Testing Rule enabled approximately one third of patients to be safely discharged after 2-hour risk stratification with no further testing. The EDACS, m-ADAPT, or HEART pathway enabled half of ED patients to be rapidly referred for objective testing.
Authors: Jason Stopyra; Anna Catherine Snavely; Brian Hiestand; Brian J Wells; Kristin Macfarlane Lenoir; David Herrington; Nella Hendley; Nicklaus P Ashburn; Chadwick D Miller; Simon A Mahler Journal: Heart Date: 2020-04-08 Impact factor: 5.994
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Authors: Dustin G Mark; Jie Huang; Dustin W Ballard; Mamata V Kene; Dana R Sax; Uli K Chettipally; James S Lin; Sean C Bouvet; Dale M Cotton; Megan L Anderson; Ian D McLachlan; Laura E Simon; Judy Shan; Adina S Rauchwerger; David R Vinson; Mary E Reed Journal: J Am Heart Assoc Date: 2021-11-06 Impact factor: 5.501
Authors: W Frank Peacock; Robert Christenson; Deborah B Diercks; Christian Fromm; Gary F Headden; Christopher J Hogan; Erik B Kulstad; Frank LoVecchio; Richard M Nowak; Jon W Schrock; Adam J Singer; Alan B Storrow; Joely Straseski; Alan H B Wu; Daniel P Zelinski Journal: Acad Emerg Med Date: 2020-03-27 Impact factor: 3.451
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