MIA 2012: Than M et al. 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial. J Am Coll Cardiol. 2012 Jun 5;59(23):2091-8.

Bottom Line ¹

For ED patients presenting with undifferentiated chest pain, a TIMI score of 0, together with a non-ischemic EKG, and a negative cTnI at 0 hours and 2 hours, can identify patients at very low-risk for having a major adverse cardiac event (MACE) in 30 days.

Why It’s Important for Emergency Medicine

• No ED physician wants to miss the diagnosis of ACS, but with over 6 million visits each year for chest pain, that’s a boat load of “rule-out ACS” admissions – the vast majority (85%) of whom do not end up having ACS at all.
• This trial tests the performance of an accelerated diagnostic protocol (ADP) – which combines clinical data (TIMI score) + a conventional biomarker (rather than using an expensive coronary CT angiogram or a scarce high-sensitivity cardiac biomarker) – to identify patients at very low risk for MACE in 30 days, and thus suitable for discharge.
• And it misses only 0.25%. That’s pretty good…

Major Points

• Only 1 out of 392 patient who met the ADP had an adverse outcome, meaning the ADP had a sensitivity of 99.7%.
• TIMI score 0 without the 2-hr cTnI missed 5 patients (3.2%).
• TIMI score 1, negative EKG, negative 0+2hr cTnI had sensitivity of 97%.

Design & Results

• Prospective observational cohort from 2 urban EDs in Australia and New Zealand.  Patients were >18 y/o, had >5 mins of symptoms consistent with ACS, and the ED physician planned on serial cTn testing.
• 2168 patients eligible; 1975 patients evaluated with the ADP.
• No patients lost to follow-up.
• 392 patients were ADP-negative; 1 patient with 30-day MACE

Criticisms

• Although only 1 patient had a MACE, 7 patients (2%) in the ADP-negative group had “nonemergent” revasculariztion, and 18.3% had some other therapeutic intervention within those 30 days.  The interventions may have affected these patient probability of developing a MACE.

Reviewed by V.Nguyen

MIA 2012 = Most Interesting Articles series of 2012

Author information

Michelle Lin, MD

ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco

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