2-hoursBottom 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…

Major Points

  • 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.

Reviewed by V.Nguyen

MIA 2012 = Most Interesting Articles series of 2012

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):2091-2098. [PubMed]
Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD


Professor of Emerg Med at UCSF-Zuckerberg SF General. ALiEM Founder @aliemteam #PostitPearls at https://t.co/50EapJORCa Bio: https://t.co/7v7cgJqNEn
Michelle Lin, MD