March 23rd, 2011

New Protocol Identifies Low-Risk Chest-Pain Patients

Investigators in the Asia-Pacific region are proposing a “reliable, reproducible, and fast” 2-hour protocol to identify chest-pain patients in the emergency department who have a low short-term risk of having a major adverse cardiac event and who may therefore be suitable for early discharge. The accelerated diagnosis protocol (ADP) consists of the TIMI score, ECG, and a point-of-care biomarker panel of troponin, creatine kinase MB, and myoglobin.

In a paper published online in the Lancet, Martin Than and colleagues report their experience using the new protocol in 3582 consecutive chest-pain patients treated at 14 EDs in the Asian-Pacific region. Of the patients, 9.8% had negative results in all 3 tests and were therefore classified by the ADP as low risk. The rate of major adverse cardiac events was 11.8% in the entire population, compared to 0.9% in the low-risk group determined by the ADP. The investigators calculated that the ADP had a sensitivity of 99.3%, a negative predictive value of 99.1%, and a specificity of 11.0%.

The investigators pointed out that “the near 10% possible reduction in patients needing prolonged assessment in this large patient group could reduce overcrowding in hospitals and emergency departments and provide earlier reassurance and greater convenience for patients.”

In an accompanying comment, Richard Body writes that “ASPECT has successfully established that an accelerated diagnostic protocol incorporating triple-marker testing successfully identifies a group of patients at very low risk of major adverse cardiac events who could reasonably be considered for early discharge. The field must now ask whether the strategy defined is indeed optimal, whether more sensitive and specific assays might improve performance, and whether these promising data will stand up to subsequent analyses of cost-effectiveness and patients’ preference.”


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