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A Risk Assessment Score and Initial High‐sensitivity Troponin Combine to Identify Low Risk of Acute Myocardial Infarction in the Emergency Department
Author(s) -
Pickering John W.,
Flaws Dylan,
Smith Stephen W.,
Greenslade Jaimi,
Cullen Louise,
Parsonage William,
Carlton Edward,
Mark Richards A.,
Troughton Richard,
Pemberton Christopher,
George Peter M.,
Than Martin P.
Publication year - 2018
Publication title -
academic emergency medicine
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.221
H-Index - 124
eISSN - 1553-2712
pISSN - 1069-6563
DOI - 10.1111/acem.13343
Subject(s) - medicine , mace , emergency department , cardiology , myocardial infarction , acute coronary syndrome , chest pain , troponin , troponin t , percutaneous coronary intervention , psychiatry
Objectives Early discharge of patients with presentations triggering assessment for possible acute coronary syndrome ( ACS ) is safe when clinical assessment indicates low risk, biomarkers are negative, and electrocardiograms ( ECG s) are nonischemic. We hypothesized that the Emergency Department Assessment of Chest Pain Score ( EDACS ) combined with a single measurement of high‐sensitivity cardiac troponin (hs‐ cT n) could allow early discharge of a clinically meaningful proportion of patients. Methods We pooled data from four patient cohorts from New Zealand and Australia presenting to an emergency department with symptoms suggestive of ACS . The primary outcome was major adverse cardiac events ( MACE ) within 30 days of presentation. In patients with a nonischemic ECG we evaluated the sensitivity for MACE and percentage low risk of every combination of high‐sensitivity cardiac troponin T (hs‐ cTnT ) concentration and high‐sensitivity cardiac troponin I (hs‐ cTnI ) concentration with EDACS . We used a standard smoothing technique on the probability density function for hs‐ cT n and EDACS and applied bootstrapping to determine the optimal threshold combinations, namely, the combination that maximized the percentage low risk with ≥98.5% sensitivity for MACE. Results From 2,536 patients, 2,258 presented without an ischemic ECG of whom 272 (12.1%) had a MACE within 30 days. The optimal threshold for hs‐ cTnI was 7 ng/L combined with an EDACS threshold of 16 (36.8% patients low risk). The optimal thresholds for hs‐ cTnT were 8 ng/L combined with an EDACS threshold of 15 (30.2% patients low risk). Conclusion Single measurements of both hs‐ cTnI and hs‐ cTnT at presentation combined with EDACS to identify over 30% of patients as low risk and therefore eligible for safe early discharge after only one blood draw.