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To assess whether the accelerated diagnostic protocol (ADP) studied in the Asia Pacific Evaluation of Chest Pain Trial (ASPECT) could be optimized to effectively risk stratify patients with symptoms suggestive of acute coronary syndrome (ACS) and allow early discharge of very-low-risk patients.Patients presenting to the emergency department (ED) with chest pain were prospectively enrolled between November 2007 and April 2010. Blood samples were analyzed at 0 and 2 hours postpresentation with a point-of-care multimarker panel (POC-MMP; troponin I [TnI], creatine kinase myocardial band [CKMB] isoenzyme fraction, and myoglobin) and a high-sensitivity cardiac troponin T assay (hsTnT). Patients received standard care. The original ADP (Thrombolysis in Myocardial Infarction [TIMI] risk score = 0, no ischemic electrocardiogram [ECG] changes, and the multimarker panel negative) was compared with an ADP using the point of care TnI only, hsTnT only, or TIMI risk score = 0 to 1. Primary outcome was ACS within 30 days.Of the 1,000 patients recruited, 362 (36.2%) had ACS. There were 12.3% identified as low risk by the original ADP with a sensitivity for ACS of 99.2% (95% confidence interval [CI] = 97.5% to 99.8%). The ADP with the point of care TnI only or hsTnT had the same sensitivity, but identified more patients for discharge (15.0% vs. 12.3%). Including patients with a TIMI risk score of 1 identified more patients as low risk (19.7%), but with a lower sensitivity (97.0% vs. 99.2%).An ADP consisting of a TIMI risk score of 0, no new ECG changes, and negative troponin at 0 and 2 hours postpresentation safely identifies patients at low risk of ACS, in whom discharge without further evaluation can be considered.

Accelerated diagnostic pathways for risk stratification of patients presenting to the emergency department with potential acute coronary syndromes may identify very-low-risk patients safe for early discharge to outpatient care.Patients presenting with potential acute coronary syndrome to the emergency department were prospectively enrolled between November 2007 and April 2010. Patient characteristics in conjunction with 0- and 2-hour biomarkers and electrocardiograms were analyzed according to a 2-hour thrombolysis in myocardial infarction (TIMI) score and 9 other accelerated diagnostic pathways. The primary outcome was acute coronary syndrome by 30 days.Of 1,000 patients, 362 (36.2%) had a primary outcome. A pathway comprising electrocardiogram, prior ischemic heart disease, 0/2-hour troponin/creatine kinase MB fraction/myoglobin identified the highest proportion (25.0%) as low risk, with 96.1% sensitivity for the primary outcome. A pathway comprising electrocardiogram, history of ischemic heart disease, typical vs atypical symptoms, 0/2-hour troponin was the safest, with 99.7% sensitivity for the primary outcome, but only 9.0% were low risk. A pathway comprising the TIMI score with 0/2-hour troponin and electrocardiograms identified 15.5% as low risk, with a sensitivity of 99.2% for the primary outcome. This compares with standard care in which none were for outpatient care but, 3.3% had a primary outcome postdischarge within 30 days.In this relatively high-risk population, a 2-hour TIMI score safely identified significant numbers of patients suitable for early discharge to outpatient care.

Background Previous studies have shown a risk of subsequent major adverse cardiovascular events (MACEs) in patients with suspected acute coronary syndromes (ACSs) and elevated cardiac troponin. The aim of this study was to compare prognostic utility of high-sensitivity troponin with contemporary troponin assays in such patients. Methods In total, 332 patients with suspected ACS were investigated between November 2006 and April 2007; all were followed for two years. Blood samples were analysed to compare Roche Elecsys high-sensitivity troponin T (hsTnT), Abbott Architect troponin I 3rd generation (TnI 3) and Roche Elecsys troponin T (TnT), for the prediction of MACE (composite of cardiovascular death, non-fatal myocardial infarction and revascularization). Results Sixty-eight patients (20.5%) experienced MACE between discharge and two years. Receiver operating characteristic (ROC) curve derived area under the ROC curve (95% confidence intervals) for baseline hsTnT were 0.70 (0.63–0.76), TnI 3 0.66 (0.59–0.73) and TnT 0.61 (0.53–0.69). hsTnT ( P = 0.001) was superior to TnT and TnI 3 trended ( P = 0.094) to superiority but were equivalent to each other. hsTnT best stratified patients with cumulative event rates for two-year MACE of 35.6% for levels ≥99th percentile, 17.9% for levels between the limit of detection (LOD) and 99th percentile and 5.4% for levels Conclusions hsTnT outperformed contemporary TnI and TnT assays for the prediction of MACE at two years. Those with levels below the LOD for hsTnT identified a group of patients at very low risk for adverse events.