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Long-term performance of a simple algorithm for early discharge after ruling out acute coronary syndrome: a
Beat Andreas Schaer1, Daniel Jenni, Peter Rickenbacher
1University Hospital, Petersgraben 4, CH-4031 Basel, Switzerland.
Insights
A simple algorithm safely rules out acute coronary artery disease (CAD) in high-risk patients with acute chest pain (CP). This approach enables early discharge, with a high negative predictive value for future cardiac events.
Area of Science:
- Cardiology
- Emergency Medicine
Background:
- Acute chest pain (CP) is a common presentation in emergency settings.
- Accurate and timely diagnosis of acute coronary artery disease (CAD) is crucial for patient outcomes.
- Risk stratification algorithms aid in managing patients with suspected CAD.
Purpose of the Study:
- To evaluate the short- and long-term performance of a simple algorithm for detecting or ruling out acute coronary artery disease (CAD).
- To assess the safety and efficacy of early discharge for high-risk patients presenting with acute CP.
Main Methods:
- Prospective, multicenter study involving 161 high-risk patients with acute CP.
- Exercise testing (ET) performed within 24 hours if initial troponin and ECG were normal.
- 30-day and 1-year follow-ups to monitor for adverse cardiac events.
Main Results:
- 76% of patients were discharged within 24 hours.
- The algorithm demonstrated a sensitivity of 71% and a negative predictive value of 96.4% for detecting CAD.
- The annual event rate during follow-up was 3.1%, including one fatal myocardial infarction.
Conclusions:
- Early discharge within 24 hours is safe for high-risk CAD patients with normal serial troponin and ECG, and negative exercise testing.
- The evaluated algorithm effectively rules out acute coronary artery disease in the majority of patients presenting with acute chest pain.
Study Objectives:
To test the short- and long-term performance of a simple algorithm to detect or rule out acute coronary artery disease (CAD) in patients referred with acute chest pain (CP).
Design:
Prospective, multicenter study with 30-day and 1-year follow-ups.
Setting:
Emergency and coronary care units of two university hospitals and four affiliated teaching hospitals in a suburban region of northern Switzerland.
Patients:
One hundred sixty-one consecutive patients referred with acute CP with a high CAD risk profile underwent exercise testing (ET) within 24 h if results of two troponin tests and ECG remained normal within 6 h. The patients were discharged if ET results were negative or underwent angiography if the results were positive.
Measurements And Results:
The primary end point was survival free of death, myocardial infarction (MI), and acute coronary syndrome, as well as the correct diagnosis of CAD in need of revascularization. Failure of the algorithm included events not predicted and false-positive ET results. Symptom-limited ET was performed in 142 patients, and stress imaging was performed in 17 patients. Discharge within 24 h was possible in 76%. Angiography in 21 patients showed no CAD in 4 patients, whereas revascularization was necessary in 17 patients. During follow-up, three patients had an MI (one fatal) and two patients had unstable angina, for an event rate of 3.1%/yr. Overall sensitivity of the algorithm to detect CAD was 71%, whereby six of seven false-positive ET results were due to exercise-induced CP without ECG changes. More importantly, the negative predictive value was 96.4%, indicating that this simple algorithm failed to identify only 3.6% of patients at risk for future events.
Conclusions:
Discharge within 24 h after onset of acute CP in high-risk CAD patients is safe, irrespective of CAD history, if ECG findings remain unchanged and troponin test results are normal within 6 h, and if results of adequate ET are negative.
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