Bottom Line 1
For ED patients presenting with undifferentiated chest pain, a TIMI score of 0, together with a non-ischemic EKG, and a negative cTnI at 0 hours and 2 hours, can identify patients at very low-risk for having a major adverse cardiac event (MACE) in 30 days.
Why It’s Important for Emergency Medicine
- No ED physician wants to miss the diagnosis of ACS, but with over 6 million visits each year for chest pain, that’s a boat load of “rule-out ACS” admissions – the vast majority (85%) of whom do not end up having ACS at all.
- This trial tests the performance of an accelerated diagnostic protocol (ADP) – which combines clinical data (TIMI score) + a conventional biomarker (rather than using an expensive coronary CT angiogram or a scarce high-sensitivity cardiac biomarker) – to identify patients at very low risk for MACE in 30 days, and thus suitable for discharge.
- And it misses only 0.25%. That’s pretty good…
- Only 1 out of 392 patient who met the ADP had an adverse outcome, meaning the ADP had a sensitivity of 99.7%.
- TIMI score 0 without the 2-hr cTnI missed 5 patients (3.2%).
- TIMI score 1, negative EKG, negative 0+2hr cTnI had sensitivity of 97%.
Design & Results
- Prospective observational cohort from 2 urban EDs in Australia and New Zealand. Patients were >18 y/o, had >5 mins of symptoms consistent with ACS, and the ED physician planned on serial cTn testing.
- 2168 patients eligible; 1975 patients evaluated with the ADP.
- No patients lost to follow-up.
- 392 patients were ADP-negative; 1 patient with 30-day MACE
- Although only 1 patient had a MACE, 7 patients (2%) in the ADP-negative group had “nonemergent” revasculariztion, and 18.3% had some other therapeutic intervention within those 30 days. The interventions may have affected these patient probability of developing a MACE.
MIA 2012 = Most Interesting Articles series of 2012