Research Scholarship Grant: Prof Louise Cullen

Identifying safe methods to assess patients with chest pain and potential heart disease more quickly than the current process.

Grant ID: EMRF-12-175-CULLEN

Lay Summary

This study is important because it will more rapidly move patients out of acute beds. It will do this by diagnosing patients with heart attacks up to four hours earlier and allowing earlier testing of patients without a heart attack but with potential heart disease, thus preventing overnight admissions. Approximately 80 per cent of patients who present to our ED each year with chest pain do not have a heart problem. Therefore, early discharge or admission of these patients would free up significant hospital resources, improve hospital flows and reduce the economic burden on the health care system.
It may also reduce mortality associated with overcrowding. Given that overcrowding is associated with an excess of approximately 1,500 deaths per year one, the potential decrease in mortality may be significant.
Testing very low-risk patients frequently wastes time and resources and subjects patients to unnecessary provocative testing (e.g. treadmill testing). Provocative testing carries a risk of life-threatening heart rhythms or heart attack and if the test gives a false positive result further tests may be unnecessarily performed each with their own risk and complications. Identifying a very low risk cohort, who do not require extensive investigation, is the key.


Outcomes

The findings will also assist EDs in achieving the ‘4 hour rule’ that will be implemented by the federal government. Specifically, using the current chest pain pathway, EDs will only be able to meet the 4 hour rule if they admit all patients presenting to ED with potential Acute Coronary Syndrome. In contrast, the accelerated protocol will enable more rapid diagnosis and treatment and reduce unnecessary admissions in this complex group of patients.

This study will develop emergency medicine research capacity in Queensland. Specifically, we propose to take additional blood from patients and store this for future research into cardiac markers. In doing so, we acquire the capacity to rapidly test the diagnostic accuracy of new cardiac markers that are developed. This will result in Queensland becoming the leaders in testing new biomarkers and will mean that future research can be conducted without having to set up expensive and lengthy clinical trials.


Dissemination

Louise Cullen was featured in the December QWeekend Magazine as Queensland's Best and Brightest for her work on accelerated chest pain protocols. In March 2015, she presented the rapid assessment of chest pain research outcomes to the Queensland Health Minister (Hon C. Dick). This was followed up by an interview for ABC radio on the rapid assessment of chest pain in the ED.

Peer Reviewed Publications
Cullen L, Greenslade J, Menzies L, Leong A, Than M, Pemberton C, Aldous S, Pickering J, Dalton E, Crosling B, Foreman R, Parsonage WA. Time to presentation and 12-month health outcomes in patients presenting to the emergency department with symptoms of possible acute coronary syndrome. 2015. EMJ. Online ahead of print.

Greenslade JH, Parsonage W, Than M, Scott A, Aldous S, Pickering JW, Hammett CJ, Cullen L. A Clinical Decision Rule to Identify Emergency Department Patients at Low Risk for Acute Coronary Syndrome Who Do Not Need Objective Coronary Artery Disease Testing: The No Objective Testing Rule. Ann Emerg Med. 2015 Sep 10. PubMed PMID: 26363570.

Gardner LS, Nguyen-Pham S, Greenslade J, Parsonage W, D’Emden M, Than M, Aldous S, Brown AFT, Cullen L. Admission glycaemia and its association with acute coronary syndrome in Emergency Department patients with chest pain. EMJ. 2015 Aug;32(8):608-612. PubMed PMID: 25344576

Cullen L, Greenslade J, Merollini K, Graves N, Hammett CJ, Hawkins T, et al. Cost and outcomes of assessing patients with chest pain in an Australian emergency department. Med J Aust. 2015 May 4;202(8):427-32. PubMed PMID: 25929506.

Greenslade JH, Parsonage W, Ho A, Scott A, Dalton E, Hammett C, Brown AFT, Parker K, Cullen L. Utility of routine execise stress testing among intermediate risk chest pain patients attending an emergency department. Heart Lung Circ [Internet]. 2015 May 2. PubMed PMID: 25991394.

Reichlin T, Cullen L, Parsonage WA, Greenslade J, Twerenbold R. Moehring B, et al. Two-hour algorithm for triage toward rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac troponin T. Am J Med. 2015 Apr;128(4):369-379. PubMed PMID: 25446294.

Meller B, Cullen L, Parsonage WA, Greenslade JH, Aldous S, Reichlin T, Wildi K, Twerenbold R, Jaeger C, Hillinger P, Haaf P, Puelacher C, Kern V, Rentsch K, Stallone F, Gimenez MR, Ballarino P, Basseti S, Walukiewicz A, Troughton R, Pemberton CJ, Richards AM, Chu K, Reid CM, Than M, Mueller C. Accelerated diagnostic protocol using high-sensitivity cardiac troponin T in acute chest pain patients. Int J Cardiol 2015 Apr 1;184, 208-215.

Greenslade JH, Beamish D, Parsonage W, Hawkins T, Schluter J, Dalton E, Parker K, Than M, Hammett C, Lamanna A, Cullen L. Relationship between physiological parameters and acute coronary syndrome in patients presenting to the Emergency Department with undifferentiated chest pain. Journal of Cardiovascular Nursing. 2015; Feb 5. PubMed PMID: 25658187.

Greenslade JH, Kavsak P, Parsonage W, Shortt C, Than M, Pickering JW, Aldous S, and Cullen, L. Combining presentation high-sensitivity cardiac troponin I and glucose measurements to rule-out an acute myocardial infarction in patients presenting to emergency department with chest pain. Clinical Biochemistry. 2014; 48(4-5) 288-291.

Reichlin T, Cullen L, Parsonage WA, Greenslade JH, Twerenbold R, Reiter M, Moehring B, Wildi K, Mueller S, Zellweger C, Mosimann T, Giminez MR, Haaf P, Rentsch K, Osswald S, and Mueller C. Two hour algorithm for triage towards rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac Troponin T. American Journal of Medicine. 2015 Apr;128(4):369-79 e4. PubMed PMID: 25446294.

Than M, Flaws D, Sanders S, Doust J, Glaziou P, Kline J, Aldous S, Troughton R, Reid, C, Parsonage WP, Frampton C, Greenslade JH, Deely JM, Hess E, Sadiq AB, Singleton R, Shopland R, Vercoe L, Woolhouse-Williams M, Ardagh M, Bossuyt, P, Bannister L, Cullen L. Development and validation of the Emergency Department Assessment of Chest pain Score and 2h accelerated diagnostic protocol. EMA 2014;26(1)33-44.

Cullen L, Greenslade JH, Than M, Aldous S, Chu K, Richards AM, Pemberton CJ, George P, Parsonage WA. The New Vancouver Chest Pain Rule using troponin as the only biomarker: an external validation study. AJEM 2014;32(2):129-134.

Than M, Aldous S, Lord SJ, Goodacre S, Frampton CM, Troughton R, George P, Florkowski CM, Ardagh M, Smyth D, Jardine DL, Peacock WF, Young J, Hamilton G, Deely JM, Cullen L, Richards AM. A 2-hour Diagnostic Protocol for Possible Cardiac Chest Pain in the Emergency Department A Randomised Clinical Trial. JAMA Internal Medicine 2014;174(1):51-58.

Cullen L, Aldous S, Than M, Greenslade JH, Tate JR, George PM, Hammett CJ, Richards AM, Ungerer JP, Troughton RW, Brown AF, Flaws DF, Lamanna A, Pemberton CJ, Florkowski C, Pretorious CJ, Chu K, Parsonage WA. Comparison of high sensitivity Troponin T and I assays in the diagnosis of non-ST elevation acute myocardial infarction in emergency patients with chest pain. Clinical Biochemistry 2014;47(6):321-326.

Parsonage WA, Tate J, Greenslade JH, Hammett CJ, Ungerer JP, Pretorious CJ, Brown AF, Cullen L. Effect of recalibration of the hs-TnT assay on diagnostic performance. Clinical Chemistry and Laboratory Medicine 2014;52(2):E25-E27.

Parsonage W, Greenslade JH, Hammett CJ, Lamanna A, Tate JR, Ungerer JP, Chu K, Than, M, Brown AFT, Cullen L. Validation of an accelerated high-sensitivity troponin T assay protocol in an Australian cohort with chest pain. MJA 2014;200(3):161- 5.

Conference Proceedings/Abstracts

Skoien W, Cullen L, Ashover S. Sippel J, Bettens V, Parsonage W. Outcomes of the Queensland accelerated chest pain risk evaluation (ACRE) project. Heart, Lung and Circulation. 2015 Jan 1;24:s159.

Menzies L, Cullen L, Greenslade J, Leong A, Than M, Pemberton C, et al. The association of delay in presentation and 12-month health outcomes in emergency patients with symptoms of possible acute coronary syndromes. Heart, Lung and Circulation. 2015 Jan 1;24(3):s167-s168.

Parsonage W, Cullen L, Greenslade J, Tate J, Ungerer J, Hammett C, Pretorius C, Chu K, Brown AFT. Comparison of highly sensitive Troponin I and T results in the diagnosis of acute myocardial infarction. J Am Coll Cardiol. 2013;61:E228.

George T, Cullen L, Parsonage W, Larsen P, Coverdale S, Ashover S, Bilesky J, Bailey K, Boulton B, Gibson J, Currie J. Use of an Accelerated Diagnostic Protocol in the Assessment of Emergency Department Patients with Possible Acute Coronary Syndrome. Heart, Lung and Circulation. 2013;22:S53-S

Cullen, L. Chest Pain Assessment: Time for Change. 32nd ACEM Annual Scientific Meeting (ASM). Brisbane, 22-26th November. Invited oral presentation

Greenslade, J. The costs of assessing patients with chest pain in an Australian Emergency Department.
32nd ACEM Annual Scientific Meeting (ASM). Brisbane, 22-26th November. Invited oral presentation.

Cullen, L. The cost of change. Can you afford not to? 8th Asian Conference on Emergency Medicine – Taiwan, 7-10 November 2015. Invited oral presentation.

Invited Expert
Cullen, L. Chest Pain Assessment: Time for Change. 32nd ACEM Annual Scientific Meeting (ASM). Brisbane, 22-26th November. Invited oral presentation

Greenslade, J. The costs of assessing patients with chest pain in an Australian Emergency Department.
32nd ACEM Annual Scientific Meeting (ASM). Brisbane, 22-26th November. Invited oral presentation.

Cullen, L. The cost of change. Can you afford not to? 8th Asian Conference on Emergency Medicine – Taiwan, 7-10 November 2015. Invited oral presentation.

Cullen, L. Invited Participant, Acute Coronary Syndrome Clinical Care Standard Workshop, Australian Commission on Safety and Quality in Health Care, Sydney, NSW

Cullen, L. Invited Reviewer. Map of Medicine – Cardiology Pathways: Chest pain and Atrial Fibrillation
Metro North Medicare Local

Cullen, L. Advisor, Chest Pain Pathway Minimum Dataset. Office of the Chief Health Officer, NSW Government

Cullen, L. Honorary Consultant - Acute Coronary Syndromes Capability Framework. National Heart Foundation of Australia

Cullen, L. Invited Member, EMCREG-International Steering Committee Emergency Medicine Cardiac Research and Education Group (US)

Cullen, L. Invited member, the GREAT Association. Global Research on Acute conditions Team An international network between experts operating in the management of acute clinical conditions in the field of Emergency Medicine. (Italy)


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Amount Awarded
$225,000


Program


Grant Scheme


Status
Complete


Principal Investigator:
Prof Louise Cullen


Supervisor:
Prof Anthony Brown Prof Gerry Fitzgerald


Institution



CONTACT US +61 7 3720 5700 info@emfoundation.org.au 2/15 Lang Parade Milton Qld 4064