ࡱ> _a^ bjbj 4bss% ]]]]]qqq8Lq!t^"999999%!'!'!'!'!'!'!,"#%S!]99999S!=]]99h!===9]9]9%!=9%!==:i,+K^ !~!0!Rb&=b&=\]M 999S!S!=999!9999b&999999999 + #:   1/21/16 Journal Club Handout Background and OverviewArticle Title/CitationIdentifying Patients Suitable for Discharge After a Single-Presentation High-Sensitivity Troponin Result: A Comparison of Five Established Risk Scores and Two High-Sensitivity Assays Carlton et al. (2015). Ann Emerg Med, 66(6), pp. 635645.e1Study objectives/purpose (and research hypothesis if applicable)Compare how well 5 established AMI risk scores identify patients with suspected ACS who are suitable for discharge after 1 high sensitivity troponin result.Brief Background (why issue is important, summary of previous literature)Chest pain (CP) is a very common complaint in the ED. Of the over 6 million people who complain of CP in the ED 15-25% will be diagnosed with acute coronary syndrome (ACS). Current guidelines recommend serial troponins which leads to protracted assessment. Longer ED stays leads to increased cost, ED crowding, and increased AEs High sensitivity troponins may be used to decrease serial testing intervalFunding SourcesCollege of Emergency Medicine of the UK Bournemouth University Dr. Carlton received funding from Abbott Dr. Greaves received funding from AstraZeneca and Takeda UKMethodsPatient selection and Enrollment (inclusion/exclusion criteria, sample size etc.)Sample Size: 959 Inclusion criteria: ( 18 yo ( 5 min CP suggestive of ACS Attending deemed that eval with serial trops was required Exclusion criteria: Presence of ST elevation, LBBB not know to be old, or other EKG changes diagnostic for ischemia Arrhythmias ( 80yo Atypical symptoms in absence of chest discomfort Clear non-ACS cause of CP Another condition requiring hospitalization Refused to consent Non-English speaking Pregnant Renal failure requiring dialysis Inability to be contacted after discharge Troponin @ presentation was not availableStudy design and Methodology (type of trial, randomization, blinding, Controls, study groups, Length of study, etc.)Type: Prospective cohort study (planned post hoc analysis) Setting: 1 UK district general hospital Study Groups: Troponin-T vs. Troponin-I Length of Study: July 2012 to August 2013Interventions (if applicable) Troponin-I Troponin-T Risk Scores (see figure 1): Modified Goldman Thrombolysis in Myocardial Infarction (TIMI) Global Registry of Acute Cardiac Events (GRACE) History, EKG, Age, Risk Factors, Troponin (HEART) Vancouver Chest Pain RuleOutcome measures/EndpointsPrimary Endpoint: Fatal or non-fatal AMI occurring within 30 days of hospital attendance (change in trop, EKG changes, or imaging evidence of ischemia)Statistical analysisChi squared analysis Thresholds that needed to be met: Sensitivity ( 98% NPV ( 99.5% ( 30% identified as suitable to dischargeResultsEnrollment & Baseline CharacteristicsSee table 1Summary of primary & secondary outcomes (including subgroup analysis, etc. include both efficacy and safety parameters)AMI in 30 days: 8.2% in troponin-T group 7.6% in troponin-I group Met thresholds: No combo of 1 risk score with either troponin TIMI ( 1 + Goldman ( 1 + troponin-T TIMI = 0 + HEART ( 3 + troponin-IDiscussion and ConclusionsBrief summary of authors main discussion pointsSeveral diagnostic algorithms do not have potential to achieve the diagnostic sensitivity threshold of >98% Possible to identify ( 30% of pts suitable for early discharge with NPV ( 99.5% Introduction of adjunctive risk scoring in combo with single trop has potential to reduce LOS for low risk pts and allow discharge after single blood draw Wide variability in diagnostic performance when combining trop and risk scoresAuthors conclusionsMay be possible to identify low risk patients using a single high sensitivity troponin at presentationStudy strengthsUse of established, validated risk scoring systems Large sample sizeStudy limits, weakness, Potentials for bias, etc.Low prevalence of primary endpoint (8%) Single site Risk of incorporation bias (test being evaluated is included in reference standard) due to outcome being based on hs-trop Risk of misclassification bias (subjects are incorrectly categorized with respect to their exposure status or outcome) due to use of trop-T for outcome adjudication Endpoint excluded unstable angina, revascularization, etc which some scores were designed to identify Treating physicians used the Goldman score to eval patients which may explain superior diagnostic performance Doesnt take into acct clinical gestalt (makes 100% sensitivity possible)Applicability & impact On healthcare providersCurrently, troponin is repeated in most EDs at 3 hours after presentation with good confidence. A study published in 2011 (Keller T et al. JAMA 2011 Dec 28; 306: 2684) found the sensitivity and NPV at 3 hours for both assays were 98% and 99%, respectively for hs-trop-I. The results of the current study are very complex and unfortunately dont take clinician gestalt into account. Clinical practice is unlikely to change because of these results. Check these out:  HYPERLINK "http://www.thennt.com/risk/low-risk-chest-pain-over-age-40/" http://www.thennt.com/risk/low-risk-chest-pain-over-age-40/  HYPERLINK "http://www.thennt.com/risk/low-risk-chest-pain-under-age-40/" http://www.thennt.com/risk/low-risk-chest-pain-under-age-40/  HYPERLINK "http://www.thennt.com/nnt/aspirin-for-major-heart-attack/" http://www.thennt.com/nnt/aspirin-for-major-heart-attack/  HYPERLINK "http://www.thennt.com/nnt/thrombolytics-for-major-heart-attack/" http://www.thennt.com/nnt/thrombolytics-for-major-heart-attack/  HYPERLINK "http://www.thennt.com/nnt/aspirin-to-prevent-a-first-heart-attack-or-stroke/" http://www.thennt.com/nnt/aspirin-to-prevent-a-first-heart-attack-or-stroke/     PAGE  PAGE 3 6N   * 3 A \ 3 l μxjxP?x?x2xhJ1heOJQJ^J hJ1h=CJOJQJ^JaJ2hJ1hj#B*OJQJ^JfHph...q hJ1hj#6OJQJ^JhJ1hj#OJQJ^J+hJ1h}@,0J5B*OJQJ\^Jph...'hJ1h}@,5B*OJQJ\^Jph...hJ1h=OJQJ^J#hJ1h=5CJOJQJ^JaJh=hYK OJQJ^J#hhYK >*CJ OJQJ^JaJ #hhf >*CJ OJQJ^JaJ 67N B {r\S $Ifgdj#$-D9DIfM gdJ1 $IfgdJ1pkd$$Ifl * t0644 lap ytJ1 $$Ifa$gdJ1gdf B C \ ! vmd[ $Ifgdj# $Ifgd= $Ifgd=kd$$Ifl0 * t0644 lapytJ1! 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