Safety of accelerated diagnostic protocols for acute coronary syndrome in a resource-limited public health system

Background Although most patients who present to the emergency department with chest pain are at low risk of adverse events, clinicians must identify higher-risk patients while safely ruling out acute coronary syndrome (ACS) and other serious conditions. In resource-limited public health systems, timely outpatient follow-up after discharge may be difficult to ensure. Objectives To evaluate the performance of accelerated diagnostic protocols (ADPs) among patients with chest pain in a resource-limited public health system. Methods We conducted a study of patients presenting with suspected ACS excluding ST-segment elevation and instability. ADP scores were calculated but not used for clinical decisions. The primary outcome was a major adverse cardiac event (death, acute myocardial infarction or revascularization) within 30 days. We evaluated the negative predictive value (NPV) and area under the receiver operating characteristic curve (AUC) of each score. Results Of the 105 patients screened, 93 were included and had complete follow-up. Median age was 59 years. The primary outcome occurred in 11 patients. Patients were classified as low risk in 24.7% (T-MACS), 40.9% (TIMI), 33.3% (HEART), and 38.7% (EDACS) of cases. NPVs were 91.3%, 94.7%, 96.8%, and 100%, respectively. AUCs were 0.70, 0.70, 0.77, and 0.75, respectively, with no significant differences between scores (p=0.19). Conclusions In this small, single-center cohort, the four ADPs had similar discrimination. EDACS and HEART classified a clinically meaningfully higher proportion of patients as low risk and had high negative predictive values; however, the limited sample size and event count preclude definitive conclusions about discharge safety. Larger prospective studies are needed before these findings can guide routine practice.