Simplified Predictive Instrument to Rule Out Acute Coronary Syndromes in a High-Risk Population.
Abstract
BACKGROUND: It is unclear whether diagnostic protocols based on cardiac markers to
identify low-risk chest pain patients suitable for early release from the emergency
department can be applied to patients older than 65 years or with traditional cardiac
risk factors. METHODS AND RESULTS: In a single-center retrospective study of 231 consecutive
patients with high-risk factor burden in which a first cardiac troponin (cTn) level
was measured in the emergency department and a second cTn sample was drawn 4 to 14
hours later, we compared the performance of a modified 2-Hour Accelerated Diagnostic
Protocol to Assess Patients with Chest Pain Using Contemporary Troponins as the Only
Biomarker (ADAPT) rule to a new risk classification scheme that identifies patients
as low risk if they have no known coronary artery disease, a nonischemic electrocardiogram,
and 2 cTn levels below the assay's limit of detection. Demographic and outcome data
were abstracted through chart review. The median age of our population was 64 years,
and 75% had Thrombosis In Myocardial Infarction risk score ≥2. Using our risk classification
rule, 53 (23%) patients were low risk with a negative predictive value for 30-day
cardiac events of 98%. Applying a modified ADAPT rule to our cohort, 18 (8%) patients
were identified as low risk with a negative predictive value of 100%. In a sensitivity
analysis, the negative predictive value of our risk algorithm did not change when
we relied only on undetectable baseline cTn and eliminated the second cTn assessment.
CONCLUSIONS: If confirmed in prospective studies, this less-restrictive risk classification
strategy could be used to safely identify chest pain patients with more traditional
cardiac risk factors for early emergency department release.
Type
Journal articleSubject
acute coronary syndromeschest pain
coronary disease
emergency department
risk classification
Acute Coronary Syndrome
Aged
Biomarkers
Chest Pain
Decision Support Techniques
Electrocardiography
Emergency Service, Hospital
Female
Humans
Male
Middle Aged
Retrospective Studies
Risk Factors
Troponin C
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https://hdl.handle.net/10161/12507Published Version (Please cite this version)
10.1161/JAHA.115.002351Publication Info
Fanaroff, Alexander C; Schulteis, Ryan D; Pieper, Karen S; Rao, Sunil V; & Newby,
L Kristin (2015). Simplified Predictive Instrument to Rule Out Acute Coronary Syndromes in a High-Risk
Population. J Am Heart Assoc, 4(12). 10.1161/JAHA.115.002351. Retrieved from https://hdl.handle.net/10161/12507.This is constructed from limited available data and may be imprecise. To cite this
article, please review & use the official citation provided by the journal.
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Show full item recordScholars@Duke
Alexander Fanaroff
House Staff
Laura Kristin Newby
Professor of Medicine
Research Description General Focus: Clinical investigation the process and treatment
of acute and chronic coronary artery disease and systems issues for delivery of care
to patients with these illnesses. Particular interests include management of patients
with chest pain and unstable angina, evaluation of the use of biochemical markers
other than CK-MB for diagnosis and risk stratification in these patients, issues related
to coronary artery disease in women, and systems issues
Sunil Vadlakonda Rao
Adjunct Professor in the Department of Medicine
Focus of research is in the radial approach to PCI, transfusion physiology and outcomes
in patients with ischemic heart disease, quality assessment and improvement through
registries, and clinical trials in interventional cardiology
Ryan D Schulteis
Assistant Professor of Medicine
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