Noel Stevenson Research Scholarship: 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

Project 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

Professor Cullen and her research colleagues have developed new diagnostic tools and procedures aimed at reducing door-to-discharge times in patients with suspected acute coronary syndromes. In her PhD research, Professor Cullen showed that her new accelerated diagnostic protocol, ImpACT, was safe and effective at identifying low risk patients who can be managed in an outpatient setting. Using the protocol, more 20% of patients presenting to the ED with chest pain could be safely discharged.

Leveraged Funds

Dissemination

Journal publications:
• Cullen L., Greenslade J., Menzies L. et al, “Time to presentation and 12-month health outcomes in patients presenting to the emergency department with symptoms of possible acute coronary syndrome”, Emergency Medicine Journal, 2016; 33(6):390-5
• Greenslade J.H., Parsonage W., Than M. et al, “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., 2016; 67(4): 478-489
• Greenslade J.H., Beamish D., Parsonage W., et al, “Relationship between physiological parameters and acute coronary syndrome in patients presenting to the Emergency Department with undifferentiated chest pain”, Journal of Cardiovascular Nursing, 2016; 31(3):267-73
• Gardner L.S., Nguyen-Pham S., Greenslade J. et al, “Admission glycaemia and its association with acute coronary syndrome in Emergency Department patients with chest pain.” Emerg Med J., 2015; 32(8):608-612
• Cullen L., Greenslade J., Merollini K., et al. “Cost and outcomes of assessing patients with chest pain in an Australian emergency department.” Med J Aust., 2015; 202(8):427-32
• Greenslade J.H., Parsonage W., Ho A. et al, “Utility of routine exercise stress testing among intermediate risk chest pain patients attending an emergency department.”, Heart Lung Circ., 2015; 24(9): 879-84
• Reichlin T., Cullen L., Parsonage W.A., 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;128(4):369-37p
• Meller B., Cullen L., Parsonage W.A., et al, “Accelerated diagnostic protocol using high-sensitivity cardiac troponin T in acute chest pain patients”, Int J Cardiol, 2015;184; 208-215
• Greenslade J.H., Kavsak P., Parsonage W., et al, “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 W.A., et al, “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;128(4):369-79
• Than M., Flaws D., Sanders S., et al, “Development and validation of the Emergency Department Assessment of Chest pain Score and 2h accelerated diagnostic protocol”, Emergency Medicine Australas, 2014;26(1):33-44
• Cullen L., Greenslade J.H., Than M., et al, “The New Vancouver Chest Pain Rule using troponin as the only biomarker: an external validation study”, American Journal of Emergency Medicine, 2014;32(2):129-134
• Than M., Aldous S., Lord S.J., et al, “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., et al, “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 W.A., Tate J., Greenslade J.H., et al, “Effect of recalibration of the hs-TnT assay on diagnostic performance”, Clinical Chemistry and Laboratory Medicine, 2014;52(2):E25-E27
• Parsonage W., Greenslade J.H., Hammett C.J., et al, “Validation of an accelerated high-sensitivity troponin T assay protocol in an Australian cohort with chest pain”, MJA, 2014;200(3):161- 5

Conference presentations/abstracts:
• Skoien W., Cullen L., Ashover S., et al , “Outcomes of the Queensland accelerated chest pain risk evaluation (ACRE) project”, Heart, Lung and Circulation, 2015; 1;24:s159.
• Menzies L., Cullen .L, Greenslade J., 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., et al, “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., et al, “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
• Cullen L., Acute Coronary Syndrome Clinical Care Standard Workshop, Australian Commission on Safety and Quality in Health Care, Sydney, NSW: Invited Participant
• Cullen L., Map of Medicine – Cardiology Pathways: Chest pain and Atrial Fibrillation; Metro North Medicare Local: Invited Reviewer
• Cullen L., Chest Pain Pathway Minimum Dataset, Office of the Chief Health Officer, NSW Government: Advisor
• Cullen L., Coronary Syndromes Capability Framework, National Heart Foundation of Australia: Honorary Consultant
• Cullen L., EMCREG-International Steering Committee Emergency Medicine Cardiac Research and Education Group (US): Invited Member
• Cullen L., 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): Invited member

Media:
-The-Courier Mail, Qweekend, The year’s leaders in the arts, sciences, sport, technology, fashion, food, education and ideas, 7 December 2015
- ABC Radio & ABC Evening News report, 9 November 2013