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A 0-Hour/1-Hour Protocol for Safe, Early Discharge of Chest Pain Patients

Mokhtari, Arash LU ; Lindahl, Bertil; Schiopu, Alexandru LU ; Yndigegn, Troels LU ; Khoshnood, Ardavan LU ; Gilje, Patrik LU and Ekelund, Ulf LU (2017) In Academic Emergency Medicine 24(8). p.983-992
Abstract

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-... (More)

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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author
organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
Chest Pain, ACS, Acute Corotany Syndrome, Troponin T, TnT
in
Academic Emergency Medicine
volume
24
issue
8
pages
10 pages
publisher
Wiley-Blackwell
external identifiers
  • scopus:85026379099
  • wos:000409257000010
ISSN
1069-6563
DOI
10.1111/acem.13224
language
English
LU publication?
yes
id
5d194e14-407e-4bd8-bbd3-6174eedd69f1
date added to LUP
2017-08-30 15:25:44
date last changed
2018-06-10 05:22:31
@article{5d194e14-407e-4bd8-bbd3-6174eedd69f1,
  abstract     = {<p>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 &lt; 5 ng/L or a 0-hour hs-cTnT &lt; 12 ng/L combined with a 1-hour increase &lt; 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.</p>},
  author       = {Mokhtari, Arash and Lindahl, Bertil and Schiopu, Alexandru and Yndigegn, Troels and Khoshnood, Ardavan and Gilje, Patrik and Ekelund, Ulf},
  issn         = {1069-6563},
  keyword      = {Chest Pain,ACS,Acute Corotany Syndrome,Troponin T,TnT},
  language     = {eng},
  month        = {08},
  number       = {8},
  pages        = {983--992},
  publisher    = {Wiley-Blackwell},
  series       = {Academic Emergency Medicine},
  title        = {A 0-Hour/1-Hour Protocol for Safe, Early Discharge of Chest Pain Patients},
  url          = {http://dx.doi.org/10.1111/acem.13224},
  volume       = {24},
  year         = {2017},
}