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Rapid diagnostic protocol for patients with chest pain

2011; Elsevier BV; Volume: 378; Issue: 9789 Linguagem: Inglês

10.1016/s0140-6736(11)61203-8

1474-547X

Luke Hermann, David H. Newman, Reuben J. Strayer,

Emergency and Acute Care Studies

Martin Than and colleagues1Than M Cullen L Reid CM et al.A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study.Lancet. 2011; 377: 1077-1084Summary Full Text Full Text PDF PubMed Scopus (292) Google Scholar provide a potential protocol for the most common and risk-filled issue in emergency medicine: the safe and appropriate discharge of emergency department patients with chest pain. Two obstacles are of note. First, a one-size-fits-all approach, despite being common, ignores Bayesian considerations and in low-risk groups results in poor yield.2Hermann LK Weingart SD Duvall WL Henzlova MJ The limited utility of routine cardiac stress testing in emergency department chest pain patients younger than 40 years.Ann Emerg Med. 2009; 54: 12-26Summary Full Text Full Text PDF PubMed Scopus (56) Google Scholar Than and colleagues address this by identifying a group whose post-test probability of an adverse event is low enough to consider foregoing further testing. The second obstacle is a pervasive belief that the acceptable “miss rate” for acute coronary syndromes is 0%.3Slovis CM. The low-risk patient with possible acute coronary syndrome: how much evaluation is enough? Presented at the American College of Emergency Physicians Scientific Assembly; Chicago, IL, USA; Oct 27–30, 2008.Google Scholar This belief ignores both the impossibility of such accuracy and the associated costs of pursuing such a miss rate. The solution to both problems is the “test threshold”4Pauker SG Kassirer JP The threshold approach to clinical decision making.N Engl J Med. 1980; 302: 1109-1117Crossref PubMed Scopus (985) Google Scholar—a prevalence of disease above which the potential benefits of testing outweigh the potential harms. For the assessment of potential cardiac ischaemia, this threshold has been estimated at about 2%.5Kline JA The pretest probability primer.http://www.pretestconsult.com/site/Primer2_files/frame.htmGoogle Scholar Thus if either the pretest or post-test probability of disease is less than 2%, testing will be more likely to yield harm than benefit. Than and colleagues have identified a clinically relevant decision aid that identifies a group below this threshold. Consensus agreement and codification of a defined threshold would alleviate much of the perceived risk associated with decisions to forego further testing for coronary disease. From this perspective, the test threshold offers the opportunity to adhere to a Hippocratic ideal: first, do no harm. We declare that we have no conflicts of interest. Rapid diagnostic protocol for patients with chest pain – Authors' replyWe agree with Paul Collinson and Steve Goodacre that a high-quality contemporary cardiac troponin is the key biomarker in the assessment of possible cardiac chest pain and that creatine kinase MB and myoglobin add minimal extra value. Subsequent testing of stored samples from the ASPECT cohort with contemporary central laboratory cardiac troponins gave a higher sensitivity, with more patients eligible for early discharge. The cardiac troponin assay used should preferably have a cut-off at the 99th centile at a point near to the 10% coefficient of variation (CV) and no greater than the 20% CV. Full-Text PDF