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chestpain_ruleout

ACS rule out methodologies for the adult patient with chest pain in the ED

ACS risk scoring systems

Thrombolysis In Myocardial Infarction (TIMI) score

  • Score 1 point for each of:
    • Age > 65 years;
    • Three or more risk factors for coronary artery disease (family history of coronary artery disease, hypertension, hypercholesterolaemia, diabetes, current smoker);
    • Aspirin taken in the past 7 days;
    • Significant coronary stenosis (eg, documented coronary stenosis > 50%);
    • Severe angina (two or more angina events in past 24 hours, or persisting discomfort);
    • ST-segment deviation of 0.05 mV on initial ECG;
    • Increased blood troponin or creatine kinase-MB levels (during assessment)
  • Low risk for ACS: TIMI score of 0 ie. NONE of the above pertain

2006 National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (NHFA/CSANZ) guidelines

  • Unfortunately, in an ED population, adherence to these guidelines results in a small proportion (around 1%) of patients satisfying the criteria for low risk while incidence of ACS in the intermediate risk group (63% of patients) is less than 2%.

high risk for ACS

  • Repetitive or prolonged (> 10 min) chest pain/discomfort
  • Elevation of at least one cardiac biomarker (troponin or CK-MB)
  • Persistent or dynamic ST-segment depression  0.5 mm, or new T-wave inversion  2mm
  • Transient ST-segment elevation ( 0.5 mm) in more than two contiguous leads
  • Haemodynamic compromise: systolic blood pressure < 90 mmHg, cool peripheries, diaphoresis, Killip class > 1, or new onset mitral regurgitation
  • Sustained ventricular tachycardia
  • Syncope
  • Left ventricular systolic dysfunction (LVEF fraction < 40%)
  • Prior PCI (past 6 months) or CABG surgery
  • Diabetes (with typical symptoms of ACS)
  • Chronic kidney disease, eGFR < 60 mL/min/1.73 m2 (with typical symptoms of ACS)

Intermediate risk for ACS

  • No high risk features, and any of:
    • Chest pain or discomfort during rest within past 48 h, or pain that was repetitive or prolonged, but currently resolved
    • Age > 65 years
    • Coronary heart disease: prior myocardial infarction with LVEF  40% or known coronary lesion > 50% stenosed
    • Two or more of: known hypertension, family history, active smoking, hyperlipidaemia
    • Diabetes (with atypical symptoms of ACS)
    • Chronic kidney disease, eGFR < 60 mL/min/1.73 m2 (with atypical symptoms of ACS)
    • Prior aspirin use

Low risk of ACS

  • No intermediate or high risk features, and any of:
    • Onset of angina symptoms during the past month
    • Worsening in severity or frequency of angina
    • Lowering of angina threshold

Emergency Department Assessment of Chest Pain Score (EDACS)

  • incorporate subjective features with low diagnostic value and possibly cause ascertainment bias

Risk stratification studies

Improved Assessment of Chest pain Trial (IMPACT) study

  • an intervention trial at a single tertiary referral hospital (Royal Brisbane and Women’s Hospital) during February 2011 - March 2014.
  • 1366 prospectively recruited patients presenting to the ED with symptoms of suspected acute coronary syndrome (ACS) were stratified into groups at low, intermediate or high risk of an ACS.
  • rapid risk stratification tool for identifying patients at low short term (30-day) risk of an ACS who could be safely discharged home without additional cardiac testing
  • used a sensitive, but not highly sensitive, troponin assay
  • does not emphasise chest pain characteristics
  • inclusions:
    • age > 18 yrs with > 5 minutes of pain c/w ACS (acute pain in the chest, epigastrium, neck, jaw or arm, or discomfort or pressure without an apparent non-cardiac cause)
  • exclusions:
    • clear non-ACS cause for their symptoms
    • transfers from another hospital
    • pregnant
    • already recruited past 30 days
    • not consenting to study or for follow up
    • inappropriate recruitment eg. terminal illness
  • primary outcome was an ACS (acute myocardial infarction (AMI), cardiovascular death, unstable angina pectoris (UAP), or coronary revascularisation (emergency or urgent) ) within 30 days of presentation EXCLUDING Type 2 AMIs, infarction secondary to an acute imbalance between oxygen supply and demand (eg, ventricular arrhythmias, heart failure, coronary artery spasm)
  • secondary outcomes were ED and hospital lengths of stay
  • Risk categorisation criteria:
    • High risk: as for 2006 NHFA/CSANZ guidelines
    • Intermediate risk: No high risk features, and any of:
      • Age > 40 years
      • Chronic kidney disease, eGFR < 60 mL/min/1.73 m2 (with atypical symptoms of ACS)
      • Diabetes (with atypical symptoms of ACS)
    • Low risk: No intermediate or high risk features, and no diabetes
  • the study categorised 17.9% of patients as “low risk” (244 patients)
    • these patients were young (20-39 yr olds with mean age, 33.8 years)
    • 94% of these would be categorised as intermediate risk under 2006 NHFA/CSANZ guidelines
    • none of whom had experienced an ACS event by 30 days
  • 788 patients (58%) were categorised as intermediate risk and of these:
    • 683 had inpatient stress testing (primarily stress ECG)
    • 14 (1.8%) experienced an ACS event by 30 days which is above the “accepted” threshold of 1% missed adverse cardiac outcomes

Asia-Pacific ASPECT trial

  • 2-hour troponin protocol
  • categorised about 10% of patients as low risk, with 99.3% sensitivity

ADAPT Aust-NZ study of the accelerated diagnostic protocol (ADP)

  • ADP clinical pathways were applied to patients with possible cardiac chest pain once other serious causes had been considered and excluded
  • ADP Low risk category:
    • Troponin I (cTnI) level at 0 and 2 h below institutional cut-off for an elevated troponin concentration
    • No new ischaemic changes on the initial electrocardiogram (ECG)
    • Thrombolysis In Myocardial Infarction (TIMI) score of 0; ie, NONE of the following pertain:
      • Age > 65 years;
      • Three or more risk factors for coronary artery disease (family history of coronary artery disease, hypertension, hypercholesterolaemia, diabetes, current smoker);
      • Aspirin taken in the past 7 days;
      • Significant coronary stenosis (eg, documented coronary stenosis > 50%);
      • Severe angina (two or more angina events in past 24 hours, or persisting discomfort);
      • ST-segment deviation of 0.05 mV on initial ECG;
      • Increased blood troponin or creatine kinase-MB levels (during assessment)
  • 20% of patients categorised as low risk and 79% of these had outpatient testing
    • found one ACS event among 392 low risk patients (99.7% sensitivity)

Accelerated Chest pain Risk Evaluation (ACRE) project

  • implemented the ADAPT assessment protocol in 16 public hospitals across Queensland
  • evaluated pre- and post-implementation process measures and costs
  • did not assess the outcomes for individual patients
  • the statewide project achieved an estimated released capacity of $11.2 million through reduced admission rates and $2.3 million through shorter hospital stays, impressive gains in view of the fact that only 20% of patients with chest pain were managed on the accelerated pathway
  • Further savings could be realised should expanding the approach to groups with higher risk prove possible, as in the IMPACT trial.
chestpain_ruleout.txt · Last modified: 2017/11/09 16:15 (external edit)