Program of research incorporating six studies to improve the assessment and diagnosis of chest pain.

The aim of this study is to prospectively investigate the accuracy and safety of an accelerated’ chest pain diagnostic pathway (ANZAP rule) in patients presenting with intermediate risk chest pain in an Australian setting.

Grant ID: PROG-2010-004-CULLEN-ACS

Project Summary

Chest pain is one of the most common Emergency Department (ED) presentations, but establishing a diagnosis of heart-related conditions is challenging and resource-intensive. Difficulties occur for a number of reasons. First, there are no tests available to rapidly identify all individuals who have heart conditions. Second, the symptoms of heart disease are varied and are common across a number of different illnesses. Thus, physicians who are treating patients with potential heart disease have to use a number of signs, symptoms, and tests to determine the likelihood that someone has heart disease. This process can take between 12 and 24 hours.

The researchers have conducted a significant program of research and developed a more rapid approach to diagnosing chest pain. This approach allows physicians to identify the risk of heart disease as early as 2 hours after arrival in the ED using clinical information, and blood tests. The purpose of this study is to demonstrate that the assessment process for patients presenting acutely to hospital EDs with possible cardiac chest pain is safe and accurate. This study will recruit 1000 patients presenting to the Royal Brisbane and Women’s Hospital with greater than 5 minutes chest pain who are assigned as intermediate risk of acute coronary syndromes (ACS) on initial clinical assessment. These individuals will be treated according to the newly developed protocol and followed-up for 45 days to determine the accuracy of the test in predicting patient outcomes.

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Outcomes

Prof Cullen and the team at the RBWH developed trialled the safety and evaluated the health economic benefits of the ‘Improved Assessment of Chest pain Trial’ (ImpACT) Protocol.

They showed that the ImpACT protocol is a rapid approach to diagnosing chest pain in emergency patients. It allows clinicians to safely accelerate the assessment of up to 70 per cent of emergency patients presenting with chest pain.

ImpACT was investigated at the RBWH during February 2011 to March 2014, with 1366 patients presenting to the ED with symptoms of suspected ACS stratified into groups at low, intermediate or high risk of an ACS. Low and intermediate risk patients underwent troponin testing at presentation and two hours later. Intermediate risk patients underwent objective testing after the second troponin test and low risk patients were discharged without further objective testing. Care for high risk patients was unchanged.

In 2017, the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand updated their Guidelines for the Management of Acute Coronary Syndromes (ACS), to incorporate the ImpACT protocol.

Benefits of the ImpACT Protocol i:
> Reduced the length of hospital stay for the majority of patients from 26 hours down to eight hours
> Allowed physicians to discharge a higher proportion of low-risk and intermediate-risk patients from the emergency department within four hours
> Reduced the expected cost of assessment by $1229 (in some hospitals, the assessment cost of $1600 per chest pain patient was reduced to about $600).

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IMPACT

In 2016, Queensland Health awarded the team an $800,000 grant to pilot ImpACT at the Cairns Base Hospital and potentially roll it out to further Queensland Hospitals. It has been estimated that this newer protocol could deliver additional economic benefits of $12.4 million annually if rolled out in all Queensland hospitals.

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Leveraged Funds

- $127,722 In-Kind Support
- Queensland Health: $800,000

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Dissemination

Journal publications

Pickering, J.W., Flaws, D., Smith, S.W., Greenslade, J., Cullen, L., Parsonage, W., Carlton, E., Mark Richards, A., Troughton, R., Pemberton, C. and George, P.M., 2018. A Risk Assessment Score and Initial High‐sensitivity Troponin Combine to Identify Low Risk of Acute Myocardial Infarction in the Emergency Department. Academic Emergency Medicine, 25(4), pp.434-443.

Cullen L., Greenslade, J. H., Hawkins T., Hammett C., O’Kane S., Ryan K., Parker K., Schluter J. Dalton E., Brown A.F., Than M., Peacock W.F., Jaffe A., O'Rourke P.K., Parsonage W.A., “Improved Assessment of Chest pain Trial (IMPACT): assessing patients with possible acute coronary syndromes”, Med J Aust, 2017;4;207(5):195-200

Pickering, J.W., Than, M.P., Cullen, L., Aldous, S., Ter Avest, E., Body, R., Carlton, E.W., Collinson, P., Dupuy, A.M., Ekelund, U. and Eggers, K.M., 2017. Rapid rule-out of acute myocardial infarction with a single high-sensitivity cardiac troponin T measurement below the limit of detection: a collaborative meta-analysis. Annals of internal medicine, 166(10), pp.715-724.

Jülicher, P., Greenslade, J.H., Parsonage, W.A. and Cullen, L., 2017. The organisational value of diagnostic strategies using high-sensitivity troponin for patients with possible acute coronary syndromes: a trial-based cost-effectiveness analysis. BMJ open, 7(6), p.e013653.

Cullen, L.A. and Mills, N.L., 2017. Point: the use of sex-specific cutpoints for high-sensitivity cardiac troponin assays. Clinical chemistry, 63(1), pp.261-263.

Cullen, L.A., Mills, N.L., Mahler, S. and Body, R., 2017. Early rule-out and rule-in strategies for myocardial infarction. Clinical chemistry, 63(1), pp.129-139.

Neumann, J.T., Sörensen, N.A., Ojeda, F., Schwemer, T., Lehmacher, J., Gönner, S., Jarsetz, N., Keller, T., Schaefer, S., Renné, T. and Landmesser, U., 2017. Immediate rule-out of acute myocardial infarction using electrocardiogram and baseline high-sensitivity troponin I. Clinical Chemistry, 63(1), pp.394-402.

Greenslade, J.H., Hawkins, T., Parsonage, W. and Cullen, L., 2017. Panic disorder in patients presenting to the emergency department with chest pain: prevalence and presenting symptoms. Heart, Lung and Circulation, 26(12), pp.1310-1316.

Knowlman, T., Greenslade, J.H., Parsonage, W., Hawkins, T., Ruane, L., Martin, P., Prasad, S., Lancini, D. and Cullen, L., 2017. The association of electrocardiographic abnormalities and acute coronary syndrome in emergency patients with chest pain. Academic Emergency Medicine, 24(3), pp.344-352.

Lavery, T., Greenslade, J.H., Parsonage, W.A., Hawkins, T., Dalton, E., Hammett, C. and Cullen, L., 2017. Factors influencing choice of pre‐hospital transportation of patients with potential acute coronary syndrome: A n observational study. Emergency Medicine Australasia, 29(2), pp.210-216.

Ruane, L., Greenslade, J.H., Parsonage, W., Hawkins, T., Hammett, C., Lam, C.S., Knowlman, T., Doig, S. and Cullen, L., 2017. Differences in presentation, management and outcomes in women and men presenting to an emergency department with possible cardiac chest pain. Heart, Lung and Circulation, 26(12), pp.1282-1290.

Greenslade, J.H., Parsonage, W., Than, M., Scott, A., Aldous, S., Pickering, J.W., Hammett, C.J. and Cullen, L., 2016. 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. Annals of emergency medicine, 67(4), pp.478-489.

Cheng, Q., Greenslade, J.H., Parsonage, W.A., Barnett, A.G., Merollini, K., Graves, N., Peacock, W.F. and Cullen, L., 2016. Change to costs and lengths of stay in the emergency department and the Brisbane protocol: an observational study. BMJ open, 6(2), p.e009746.

Than, M.P., Pickering, J.W., Aldous, S.J., Cullen, L., Frampton, C.M., Peacock, W.F., Jaffe, A.S., Goodacre, S.W., Richards, A.M., Ardagh, M.W. and Deely, J.M., 2016. Effectiveness of EDACS versus ADAPT accelerated diagnostic pathways for chest pain: a pragmatic randomized controlled trial embedded within practice. Annals of emergency medicine, 68(1), pp.93-102.

Greenslade, J.H., Parsonage, W., Ho, A., Scott, A., Dalton, E., Hammett, C., Brown, A.F., Parker, K. and Cullen, L., 2015. Utility of routine exercise stress testing among intermediate risk chest pain patients attending an emergency department. Heart, Lung and Circulation, 24(9), pp.879-884.

Scott, A.C., Bilesky, J., Lamanna, A., Cullen, L., FT Brown, A., Denaro, C. and Parsonage, W., 2014. Limited utility of exercise stress testing in the evaluation of suspected acute coronary syndrome in patients aged less than 40 years with intermediate risk features. Emergency Medicine Australasia, 26(2), pp.170-176.

Conference presentations/abstracts:
• Cullen, L. “Chest Pain Assessment: Time for Change.” 32nd ACEM Annual Scientific Meeting (ASM). Brisbane, 22-26th November 2015. 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 2015. 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.

Media:
• Brisbane Times, Patients with chest pain sent home faster in Qld hospital changes, 4 September 2017
• Sydney Morning Herald, “Patients with chest pain sent home faster in Queensland hospitals,” 4 September 2017
• Queensland Country Life, New tool helps rural patients with chest pain, 18 September 2017
• 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

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