EBQ:ADAPT Trial 2-Hour Troponin Rule Out

incomplete 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 ADP 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.

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 EBQ:ASPECT Trial.
• Although using the same patients, the ADAPT trial was approved at the initiation of the EBQ: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.