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?


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).


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).


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.


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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