A 2-H Diagnostic Protocol to Assess Patients With Chest Pain Symptoms in the Asia-Pacific Region (ASPECT): A Prospective Observational Validation Study

Study Questions:

How safe is a predefined 2-hour accelerated diagnostic protocol (ADP) to assess patients presenting to the emergency department with chest pain symptoms suggestive of acute coronary syndrome?

Methods:

This observational study was undertaken in 14 emergency departments in nine countries in the Asia-Pacific region, in patients ages 18 years and older, with at least 5 minutes of chest pain. The ADP included use of a structured pretest probability scoring method (Thrombolysis in Myocardial Infarction [TIMI] score), electrocardiography (ECG), and point-of-care biomarker panel of troponin, creatine kinase-myocardial band, and myoglobin. The primary endpoint was major adverse cardiac events within 30 days after initial presentation (including initial hospital attendance).

Results:

A total of 3,582 consecutive patients were recruited and completed 30-day follow-up. Of these, 421 (11.8%) patients had a major adverse cardiac event. The ADP classified 352 (9.8%) patients as low risk and potentially suitable for early discharge. A major adverse cardiac event occurred in three (0.9%) of these patients, giving the ADP a sensitivity of 99.3% (95% confidence interval [CI], 97.9-99.8), a negative predictive value of 99.1% (95% CI, 97.3-99.8), and a specificity of 11.0% (95% CI, 10.0-12.2).

Conclusions:

The authors concluded that this novel accelerated diagnostic protocol identifies patients at very low risk of a short-term major adverse cardiac event, who might be suitable for early discharge.

Perspective:

This study suggests that a 2-hour accelerated diagnostic protocol, with use of point-of-care biomarkers, ECG, and TIMI score, can safely identify patients at very low short-term risk of a major adverse cardiac event. These patients could then potentially be discharged several hours earlier to outpatient follow-up and further investigations than with present practices. The protocol used in this study has the potential to affect health service delivery worldwide, but given the low specificity (11%) of the approach, future research should continue to focus on newer methods to identify a greater proportion of patients who can be discharged earlier without significant adverse events.

Clinical Topics: Acute Coronary Syndromes, ACS and Cardiac Biomarkers

Keywords: Myocardial Infarction, Acute Coronary Syndrome, Follow-Up Studies, Biological Markers, Chest Pain, Electrocardiography


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