#EMconf: Low Risk Chest Pain Protocols

Clinical Question: What is the Safest and Most Accurate Accelerated Diagnostic Protocol (ADP) in Low-Risk Chest Pain patients in the Emergency Department for Early Discharge?

Take Home Message: Both studies have limitations, but they have been prospectively validated and are good decision aids in low-risk chest pain patients.   When comparing the ADAPT trial to the HEART Pathway, the HEART pathway was able to identify a potential absolute increase in early discharge rate of 26.8%.

Study 1:
• Study design: prospective observational validation from 2 urban emergency departments in Australia and New Zealand
Outcomes: A composite of major adverse cardiac events (MACE) within 30 days after first presentation
• The ADP (TIMI score of 0, no new ischemic ECG changes and negative serial troponins at 0 and 2 hours) was able to identify 20% of patients as low risk and suitable for early discharge
• Sensitivity and NPV of 99.7% and 99.7% respectively
• Many of the ADP negative patients still had interventions performed (74.1%)

Study 2:
• Study design: randomized controlled single-center clinical trial at a single center ED in the United States
Outcomes: Rate of objective cardiac testing within 30 days (primary).  Early discharge rates, index LOS, and cardiac-related recurrent ED visits and nonindex hospitalization at 30 days (secondary)
• The HEART Pathway (HEART score ≤ 3, serial troponins of 0 and 3 hours) was able to identify 46.8% of patients as low risk and suitable for early discharge
• Sensitivity and NPV were 100% and 100%, respectively
No patients identified as low risk had MACE at 30 days


Articles Reviewed:
Study 1: Than M, Cullen L, Aldous S, et al. 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial. J Am Coll Cardiol. 2012;59(23):2091-8
Study 2: Mahler SA, Riley RF, Hiestand BC, et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes. 2015;8(2):195-203.