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How EDs Can Evaluate, Release Chest Pain Patients More Rapidly

CHRISTCHURCH, NEW ZEALAND – The overwhelming majority of patients — 80% to 90% — who present to the ED with chest pain suspected of being cardiac related end up without an acute myocardial infarction diagnosis.

That’s why high-sensitivity assays for cardiac troponin T (hs-cTnT) have raised the interest of emergency physicians; those tests have been used to rapidly rule out acute myocardial infarction.

The problem, according to a study published recently in Annals of Internal Medicine, is to find validated evidence that the assays work well enough to allow many more patients to be discharged safely and much earlier.

Results of the collaborative meta-analysis led by Christchurch Hospital sought to reach that goal, suggesting that a single hs-cTnT concentration below the limit of detection in combination with a nonischemic ECG might successfully rule out acute myocardial infarction in patients presenting to EDs with possible emergency acute coronary syndrome.

To determine that, researchers scoured EMBASE and MEDLINE from January 2008 to Dec. 14, 2016, to identify cohort studies involving adults presenting to the ED with possible acute coronary syndrome. In those studies, an ECG and hs-cTnT measurements had been obtained, and acute myocardial infarction outcomes were determined during initial hospitalization.

EDM - ED Management - hz

Results indicate that, of 9,241 patients in 11 cohort studies, 30.6% were considered low risk, and relatively few, 0.5%, of those patients had acute myocardial infarction. Study authors note that sensitivity of the risk classification for acute myocardial infarction ranged from 87.5% to 100% in individual studies.

In most of the situations, patients evaluated for acute coronary syndrome with the cardiac troponin T assay had very low risk for acute myocardial infarction or for major adverse cardiac events (MACEs) within 30 days. Researchers say that suggests early discharge to outpatient management would be safe.

Overall, when studies were pooled, estimated sensitivity was determined to be 98.7%. At the same time, sensitivity for 30-day MACEs ranged from 87.9% to 100%, with a pooled sensitivity of 98.0%. No low-risk patients died, according to the report.