The shifting sands of chest pain assessment : Part 2

This post refers to

‘2-Hour Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker : The ADAPT Trial’  by Martin Than, Louise Cullen, Sally Aldous, William Parsonage and others published online in The Journal of the American College of Cardiology http://dx.doi.org/10.1016/j.jacc.2012.02.035

Last year I wrote under this title about the growing body of work accumulating around more rapid and safe approaches to the assessment of patients presenting with acute chest pain.

Here is a paper that takes this further and is based on a large study of an Australasian cohort of patients with undifferentiated chest pain presenting to emergency. The study refines the groups previous work published in The Lancet last year. The main refinement has been to reconfigure the accelerated diagnostic protocol (ADP) to use cardiac troponin as the only biomarker as opposed to the multi marker approach used in the earlier ASPECT study. This eliminates some of the ‘noise’ introduced by the additional biomarkers and therefore grows the size of the group that can rapidly be shown to be at low risk of a short term adverse cardiac outcome to about 20% of all comers whilst still maintaining an extremely high level of safety (a negative predictive value of >99%).

Of considerable importance is the fact that this was all achieved with testing at only 2 hours after presentation using contemporary sensitive (but not highly sensitive) troponin assays.

It’s clear that while many labs have already switched to new highly sensitive troponin assays there is still a lot to be learnt about how even the contemporary assays can be best utilised. It’s even more clear that the prevailing diagnostic paradigms for chest pain that advocate 6-8 hours of observation and testing with contemporary assays or unvalidated approaches to small changes in high sensitivity troponin assays are already in need of updating.

For additional commentary see theheart.org here

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