EBQ:ADAPT Trial 2-Hour Troponin Rule Out

Under Review Journal Club Article

Than M.. "2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial". Journal of the American College of Cardiology. 2012. 59(23):2091-2098.
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Clinical Question

Can an accelerated diagnostic protocol (ADP) for chest pain be used to identify low-risk patients suitable for discharge with close followup?

Conclusion

An accelerated diagnostic protocol of 2 negative troponins, a TIMI score < 0 and no ischemic changes on ECG. can successfully identify low risk chest pain patients for discharge from the emergency department and decrease observational stay.

Major Points

• The ADP relies on a combination of 2 negative troponins, a TIMI score < 0 and no ischemic changes on ECG.
• The ADP successfully classifies patients as low risk and has a sensitivity of 99.7 for identifying patients who will have Major Adverse Cardiac Events (MACE)
• Patients who are not low risk according to the ADP should continue to be managed with existing clinical care that involves extended observation or admission.
• Patients with a negative troponin at 0 hours and 2 hrs, a TIMI<0 and no ischemic ECG changes can be discharged with close cardiac followup.

All parameters had to be negative for the ADP to be considered negative and for the patient to be identified as low-risk

1. cTnI level at 0 and 2 h below institutional cutoff for an elevated troponin concentration
2. No new ischemic changes on the initial ECG 3. TIMI score < 0
   1. Age <65 yrs
   2. Three or more risk factors for coronary artery disease:
      1. family history of coronary artery disease
      2. hypertension
      3. hypercholesterolaemia
      4. diabetes
      5. current smoker
   3. Use of aspirin in the past 7 days
   4. Significant coronary stenosis (e.g., previous coronary stenosis >50%)
   5. Severe angina (e.g., >2 angina events in past 24 h or persisting discomfort)
   6. ST-segment deviation of 􏰆0.05 mV on first ECG
   7. Increased troponin and/or creatine kinase-MB blood tests (during assessment*)

Design

• Prospective observational validation study
• The study population was from Brisbane, Australia and Christchurch, New Zealand. These patients were from 2 of the 14 sites participating in the ASPECT Trial.
• Although using the same patients, the ADAPT trial was approved at the initiation of the ASPECT Trial.
• Patients were enrolled consecutively between November 2007 and February 2011

Population

Inclusion Criteria

• Age >18 years of age, with at least 5 min of symptoms consistent with ACS
• The attending physician planned to perform serial cTn tests

Exclusion Criteria

• ST-segment elevation myocardial infarction (STEMI)
• Cause other than ACS for the symptoms (e.g., examination findings of varicella zoster)
• Inability to provide informed consent
• Staff considered recruitment to be inappropriate (e.g., receiving palliative treatment), transfer from another hospital, pregnancy, previous enrollment, or inability to be contacted after discharge.

Interventions

Patients were either stratified to the be negative or positive for the accelerated diagnostic protocol and were then followed for 30 days with major cardiac events recorded.

Outcomes

Primary Outcomes

• No patients were lost at 30-day followup
• 392 patients were classified as ADP negative and only 1 had a major cardiac event
  • This patient 12 hour after evaluation had an MI requiring stenting

Secondary Outcomes

• Subgroup analysis classified the individual diagnostic parameters (TIMI score, ECG, and 2 sets of troponins) in various combinations identified in the following table.
• TIMI score and ECG without troponins failed to identify 5 patients with major cardiac event