Safe discharge from the cardiac emergency room with a rapid rule-out myocardial infarction protocol using serial
R Bholasingh1, R J de Winter, J C Fischer
1Department of Cardiology, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands. r.bholasingh@amc.uva.nl
Insights
A new protocol using a rapid creatine kinase-MB (CK-MB) mass assay can safely rule out myocardial infarction in chest pain patients, significantly reducing emergency room stays.
Area of Science:
- Cardiology
- Emergency Medicine
- Biomarker Assays
Background:
- Chest pain is a common emergency room presentation requiring accurate diagnosis of myocardial infarction.
- Traditional diagnostic protocols can lead to prolonged emergency room stays.
- Creatine kinase-MB (CK-MB) assays are crucial for diagnosing myocardial infarction.
Purpose of the Study:
- To evaluate a new protocol for ruling out myocardial infarction (MI) in chest pain patients.
- To assess if a rapid CK-MB (mass) assay and serial sampling can decrease emergency room length of stay.
- To determine if this protocol can be implemented without increasing patient risk.
Main Methods:
- A comparative study was conducted between patients managed with a CK-MB (activity) assay in 1994 and those managed with a rapid CK-MB (mass) assay in 1996.
- Patients were discharged from the cardiac emergency room after ruling out MI.
- Combined incidence of cardiac death and acute MI at 30 days, 6 months, and 24 months was compared.
Main Results:
- The median length of stay in the cardiac emergency room was significantly reduced from 16.0 hours in 1994 to 9.0 hours in 1996 (p < 0.0001).
- Mean event rates (cardiac death or MI) at 30 days, 6 months, and 24 months showed no significant difference between the two groups.
- Kaplan-Meier survival analysis confirmed no difference in event-free survival between the cohorts.
Conclusions:
- A protocol utilizing a rapid and sensitive CK-MB (mass) assay with serial sampling can effectively rule out myocardial infarction in chest pain patients.
- This protocol significantly reduces the length of stay in the cardiac emergency room.
- The implementation of this protocol does not compromise patient safety.
Objective:
To determine whether a new protocol, using a rapid and sensitive CK-MB(mass) assay and serial sampling, can rule out myocardial infarction in patients with chest pain and decrease their length of stay in the cardiac emergency room without increasing risk.
Design:
The combined incidence of cardiac death and acute myocardial infarction at 30 days, six months, and 24 months of follow up were compared between patients discharged home from the cardiac emergency room after ruling out myocardial infarction with a CK-MB(activity) assay in 1994 and those discharged home after a rapid CK-MB(mass) assay in 1996.
Setting:
Cardiac emergency room of a large university hospital.
Patients:
In 1994 and 1996, 230 and 423 chest pain patients, respectively, were discharged home from the cardiac emergency room with a normal CK-MB and an uneventful observation period.
Results:
The median length of stay in the cardiac emergency room was significantly reduced, from 16.0 hours in 1994 to 9.0 hours in 1996 (p < 0.0001). Mean event rates in patients from the 1994 and 1996 cohorts, respectively, were 0.9% (95% confidence interval (CI) -0.3% to 2.1%) v 0.7% (95% CI -0.1% to 1. 5%) at 30 days, 3.0% (95% CI 0.8% to 5.2%) v 2.8% (95% CI 1.2% to 4. 4%) at six months, and 7.0% (95% CI 3.7% to 10.3%) v 5.7% (95% CI 3. 5% to 7.9%) at 24 months. Kaplan-Meier survival analysis showed no difference in mean event-free survival at 30 days, six months, and 24 months of follow up.
Conclusions:
Using a rule-out myocardial infarction protocol with a rapid and sensitive CK-MB(mass) assay and serial sampling, the length of stay of patients with chest pain in the cardiac emergency room can be reduced without compromising safety.
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