Accelerated pathway in the assessment of suspected acute coronary syndrome in the Emergency Department: a diagnostic accuracy study.

Is measurement of a number of different heart hormones and chemicals two hours after an individual presents to the ED an effective way of determining suspected acute coronary syndrome in the ED?

Grant ID: PROJ-2008-002-CULLEN-ACS

Project Summary

Chest pain is one of the most common conditions treated in the Emergency Department (ED), but making a diagnosis remains challenging and resource-intensive. Not all causes of chest pain are due to heart disease. Currently, doctors do a blood test to look for the presence of a cardiac chemical called Troponin I to assist them in making a diagnosis of heart disease. This chemical is released from heart muscles when they are damaged and is, therefore, a good indicator of heart attack. However, because Troponin I is released slowly, doctors have to wait for up to six hours to determine whether it is present in the blood.

This project hopes to make a more rapid diagnosis of the patient’s chest pain by measuring several different heart hormones and chemicals two hours after an individual presents to the ED. These chemicals are known as creatine kinase-MB-isoenzyme (CK-MB), B-type natruiretic peptide (BNP), and myoglobin.

This project will recruit 1000 consecutive patients presenting to the Royal Brisbane Emergency Department with greater than 5 minutes chest pain. Patients will be managed and investigated as per standard care. However, additional blood test will be taken at two hours to assess the combination of heart chemicals. Later there will be follow-up on patients to determine whether the two hour test was accurate in diagnosing heart attack.

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Outcomes

This project led to the development of the ADAPT protocol, which was implemented in 19 Queensland Hospitals through a structured process of clinical service redesign between May 2013 and September 2015. This roll out was funded by a Queensland Health grant.

In addition, data collected for this project also contributed to an international study involving 22,651 patients from 15 international cohorts. The study measured a risk-assessment tool developed to estimate the risk of index myocardial infarction (heart attack) and of subsequent myocardial infarction or death at 30 days.

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Dissemination

- Neumann J.T., Twerenbold R., Ojeda F., Sörensen N.A., Chapman R.C., Shah A.S.V., Anand A., Boeddinghaus J., Nestelberger T., Badertscher P., Mokhtari A., Pickering J. W., Troughton R. W., Greenslade J., Parsonage W., Mueller-Hennessen M., Gori T., Jernberg T., Morris N., Liebetrau C., Hamm C., Katus H. A., Münzel T., Landmesser U., Salomaa V., Iacoviello L., Ferrario M.M., Giampaoli S. Kee F., , M.D., Thorand B,, Peters A., Borchini R., Jørgensen T., Söderberg S., Sans S., Tunstall-Pedoe H., Kuulasmaa K., Renné T., Lackner K.J., Worster A., Body R., Ekelund U., Kavsak P.A., Keller T., Lindahl B., Wild P., Giannitsis E., Than M., Cullen L.A., Mills N.L., Mueller C., Zeller T., Westermann D., Blankenberg S., “Application of High-Sensitivity Troponin in Suspected Myocardial Infarction”, N Engl J Med, 2019; 380:2529-2540. doi: 10.1056/NEJMoa1803377

- Parsonage W.A.,Milburn T., Ashover S., Skoien W., Greenslade J.H., McCormack L., Cullen L., "Implementing change: evaluating the Accelerated Chest pain Risk Evaluation (ACRE) project", Med J Aust 2017; 207 (5): 201-205

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