By far, the most promising of the publications to yet emerge from the ADAPT cohort – 1,974 patients evaluated for acute chest pain in the Emergency Department – is this re-analysis and decision instrument.
The original ADAPT publication, despite over 80% of the patients having no major cardiac event at 30 days, was only able to identify 20% of patients as “low-risk”. The HEART Score and the Vancouver Chest Pain Rule improve on this, but only incrementally. This publication, however, improves the identification of a low-risk cohort to nearly 50%. By incorporating and weighting 37 different predictor variables, then adding a layer of expert review and acceptability evaluation, these authors ultimately arrive at the “Emergency Department Assessment of Chest Pain Score (EDACS)”. Using age, gender, history, and symptoms, when combined with negative ECG and 0 and 2 hour troponins, a score of 16 constitutes a breakpoint for a decision instrument with ~99% sensitivity and ~55% specificity for MACE at 30 days.
As far as decision instruments go, it’s relatively reasonable – although, certainly, nothing you’d be able to keep in your head. Scores for age range from +2 to +20, while four different symptoms and signs have varying positive and negative values. However, in the age of computerized decision-support, at least, mildly complex rules are not as burdensome as they once were.
I would like to see, at least, prospective validation in a North American population – but this appears to be a lovely step forward.
“Development and validation of the Emergency Department Assessment of Chest pain Score and 2 h accelerated diagnostic protocol“
http://onlinelibrary.wiley.com/doi/10.1111/1742-6723.12164/abstract
It looks like this paper may already be a bit "out of date" in the sense that they would have been using the lesser sensitive troponin assays. I wonder how much of the test characteristics would have changed using the newer higher sensitive troponin assays. My guess is it would have changed the outcomes substantially.
Brian
Brian Doyle, MD FACEM FACEP
Mmm – not sure whether it's truly "out of date", because there are plenty of settings still using older troponin assays. Then – sensitivity isn't a problem with this rule. If you add in a more sensitive troponin, you'd probably end up with the same results once they specified an appropriate cut-off.
But, since this is from ADAPT – which did have a hsTnI arm – we may see them publish exactly what you're describing.