Key result
A 2-hour accelerated diagnostic protocol using a TIMI score of 0, normal ECG, and contemporary troponin assay yielded a 100% negative predictive value for 30-day major adverse cardiac events.
Why the study?
Does a 2-hour accelerated diagnostic protocol using TIMI score and contemporary troponin safely rule out 30-day MACE in ED patients with suspected ACS?
Cohort (n=840)
No
Does a 2-hour accelerated diagnostic protocol using TIMI score and contemporary troponin safely rule out 30-day MACE in ED patients with suspected ACS?
Effect estimate: NPV 100% (95% CI 95.5% to 100%)
A 2-hour accelerated diagnostic protocol using a TIMI score of 0 and contemporary troponin assays safely and accurately rules out 30-day MACE in ED patients with suspected ACS.
May support early rule-out in selected ED patients; leaves open need for randomized validation before practice change.
BACKGROUND: Recently there have been efforts to derive safe, efficient processes to rule out acute coronary syndrome (ACS) in emergency department (ED) chest pain patients. We aimed to prospectively validate an ACS assessment pathway (the 2-Hour Accelerated Diagnostic Protocol to Assess Patients with Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker (ADAPT) pathway) under pragmatic ED working conditions. METHODS: This prospective cohort study included patients with atraumatic chest pain in whom ACS was suspected but who did not have clear evidence of ischaemia on ECG. Thrombolysis in myocardial infarction (TIMI) score and troponin (TnI Ultra) were measured at ED presentation, 2 h later and according to current national recommendations. The primary outcome of interest was the occurrence of major adverse cardiac events (MACE) including prevalent myocardial infarction (MI) at 30 days in the group who had a TIMI score of 0 and had presentation and 2-h TnI assays <99th percentile. RESULTS: Eight hundred and forty patients were studied of whom 177 (21%) had a TIMI score of 0. There were no MI, MACE or revascularization in the per protocol and intention-to-treat 2-h troponin groups (0%, 95% confidence interval (CI) 0% to 4.5% and 0%, 95% CI 0% to 3.8%, respectively). The negative predictive value (NPV) was 100% (95% CI 95.5% to 100%) and 100% (95% CI 96.2% to 100%), respectively. CONCLUSIONS: A 2-h accelerated rule-out process for ED chest pain patients using electrocardiography, a TIMI score of 0 and a contemporary sensitive troponin assay accurately identifies a group at very low risk of 30-day MI or MACE.
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Kelly et al. (2014) conducted a cohort in Acute coronary syndrome (n=840). 2-Hour Accelerated Diagnostic Protocol (ADAPT) pathway vs. Standard biomarker interval was evaluated on Major adverse cardiac events (MACE) at 30 days in patients with a TIMI score of 0 and presentation and 2-h TnI <99th percentile (NPV 100%, 95% CI 95.5% to 100%). A 2-hour accelerated diagnostic protocol using a TIMI score of 0, normal ECG, and contemporary troponin assay yielded a 100% negative predictive value for 30-day major adverse cardiac events.
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