A 0-Hour/1-Hour Protocol for Safe, Early Discharge of Chest Pain Patients
Arash Mokhtari1,2, Bertil Lindahl3, Alexandru Schiopu2
1Department of Internal and Emergency Medicine, Skåne University Hospital, Lund.
Insights
An accelerated diagnostic protocol (ADP) using high-sensitivity cardiac troponin T (hs-cTnT) and clinical scores can safely rule out major adverse cardiac events (MACE) in chest pain patients. This strategy could enable early discharge for nearly 40% of emergency department patients.
Area of Science:
- Cardiology
- Emergency Medicine
- Biomarkers
Background:
- Current guidelines recommend a 0-hour/1-hour high-sensitivity cardiac troponin T (hs-cTnT) strategy for acute chest pain.
- Limited data exist on combining this hs-cTnT strategy with clinical risk stratification for improved diagnostic accuracy.
Purpose of the Study:
- To evaluate the diagnostic accuracy of an accelerated diagnostic protocol (ADP).
- To assess the combination of a 0-hour/1-hour hs-cTnT strategy, adapted Thrombolysis In Myocardial Infarction (TIMI) score, and electrocardiogram (ECG) for ruling out 30-day major adverse cardiac events (MACE).
Main Methods:
- Prospective observational study of consecutive emergency department (ED) chest pain patients.
- Collected TIMI score variables, ED physician ECG assessments, and 0- and 1-hour hs-cTnT levels.
- Defined 30-day MACE as acute myocardial infarction (AMI), unstable angina (UA), cardiogenic shock, ventricular arrhythmia, atrioventricular block, cardiac arrest, or cardiac/unknown death.
Main Results:
- The ADP identified 432 (42.4%) patients as very low risk for 30-day MACE.
- Achieved a negative predictive value of 99.5% for MACE.
- Missed only two cases of UA and no cases of AMI or other MACE.
Conclusions:
- The ADP, utilizing the 0-hour/1-hour hs-cTnT strategy and clinical risk factors, effectively identifies very low-risk patients.
- This protocol can potentially facilitate the safe early discharge of approximately 40% of ED chest pain patients.
- No further cardiac testing is needed for patients identified as very low risk by this ADP.
Objectives:
Guidelines recommend a 0-hour/1-hour high-sensitivity cardiac troponin T (hs-cTnT) diagnostic strategy in acute chest pain patients. There are, however, little data on the performance of this strategy when combined with clinical risk stratification. We aimed to evaluate the diagnostic accuracy of an accelerated diagnostic protocol (ADP) using the 0-hour/1-hour hs-cTnT strategy together with an adapted Thrombolysis In Myocardial Infarction (TIMI) score and electrocardiogram (ECG) for ruling out major adverse cardiac events (MACE) within 30 days.
Methods:
This prospective observational study enrolled consecutive emergency department (ED) chest pain patients. TIMI score variables, ED physicians' assessments of the ECG, and 0- and 1-hour hs-cTnT were collected. Thirty-day MACE was defined as acute myocardial infarction (AMI), unstable angina (UA), cardiogenic shock, ventricular arrhythmia, atrioventricular block, cardiac arrest, or death of cardiac or unknown cause.
Results:
A total of 1,020 patients were included in the final analysis. The combination of an adapted TIMI score ≤1, a nonischemic ECG, and either a 0-hour hs-cTnT < 5 ng/L or a 0-hour hs-cTnT < 12 ng/L combined with a 1-hour increase < 3 ng/L identified 432 (42.4%) patients as very low risk with a negative predictive value of 99.5% (95% confidence interval [CI] = 98.3%-99.9%) and a negative likelihood ratio of 0.04 (95% CI = 0.01-0.14) for 30-day MACE. The ADP missed only two patients with UA and no patients with AMI or other forms of MACE.
Conclusion:
An ADP using the guideline recommended 0-hour/1-hour hs-cTnT strategy rapidly identified patients with a very low risk of 30-day MACE including UA where no further cardiac testing would be needed. This could potentially allow safe early discharge of about 40% of ED chest pain patients.
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