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MIA 2012: Than M et al. 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary tr

Posted Jan 01 2013 9:00am
Bottom Line
For ED patients presenting with undifferentiated chest pain, a TIMI score of 0, together with a
non-ischemic EKG, and a negative cTnI at 0 hours and 2 hours, can identify patients at very
low-risk for having a major adverse cardiac event (MACE) in 30 days.

Why It’s Important for Emergency Medicine
  • No ED physician wants to miss the diagnosis of ACS, but with over 6 million visits each year for chest pain, that’s a boat load of “rule-out ACS” admissions - the vast majority (85%) of whom do not end up having ACS at all.
  • This trial tests the performance of an accelerated diagnostic protocol (ADP) - which combines clinical data (TIMI score) + a conventional biomarker (rather than using an expensive coronary CT angiogram or a scarce high-sensitivity cardiac biomarker) - to identify patients at very low risk for MACE in 30 days, and thus suitable for discharge.
  • And it misses only 0.25%.  That’s pretty good...
Major Points
  • Only 1 out of 392 patient who met the ADP had an adverse outcome, meaning the ADP had a sensitivity of 99.7%.
  • TIMI score 0 without the 2-hr cTnI missed 5 patients (3.2%).
  • TIMI score 1, negative EKG, negative 0+2hr cTnI had sensitivity of 97%.
Design & Results
  • Prospective observational cohort from 2 urban EDs in Australia and New Zealand.  Patients were >18y/o, had >5mins of symptoms consistent with ACS, and the ED physician planned on serial cTn testing.
  • 2168 patients eligible; 1975 patients evaluated with the ADP.
  • No patients lost to follow-up.
  • 392 patients were ADP-negative; 1 patient with 30-day MACE
Criticisms
  • Although only 1 patient had a MACE, 7 patients (2%) in the ADP-negative group had “nonemergent” revasculariztion, and 18.3% had some other therapeutic intervention within those 30 days.  The interventions may have affected these patient probability of developing a MACE.  
Reviewed by V.Nguyen

Reference
Than M et al, J Am Coll Cardiol, 2012 Jun 5;59(23):2091-8. Pubmed

MIA 2012  = Most Interesting Articles series of 2012
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