![]() Second, the ADAPT protocol still requires serial high-sensitivity troponin testing over 2 hours, which may limit efficiency gains in comparison with a single blood draw rule-out strategy. Risk scores specifically designed to be used in an ED population may improve the efficiency of identifying patients who may be suitable for early discharge. First, the use of the TIMI score, which was originally developed to predict mortality in patients with confirmed ACS, could be considered counterintuitive in a low-risk population. 8 As a result, expert consensus guidelines have recently recommended the modified ADAPT protocol for clinical implementation. Findings were similar when tested with a high-sensitivity troponin T assay. In this study, the sensitivity and negative predictive value (NPV) for major adverse cardiac events was >99% when a TIMI score of ≤1 was used. In a multinational prospective observational development and validation cohort study, 6 this method identified approximately 40% of low-risk patients who were potentially suitable for early discharge. The modified 2-Hour Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker (ADAPT) protocol 6 utilizes a combination of the Thrombolysis In Myocardial Infarction (TIMI) risk score together with 0- and 2-hour high-sensitivity troponin I results. Yet, where such combination strategies have been used, they have shown considerable promise. 11 Although this list has undoubtedly grown since then, the majority of risk scores have not been tested in combination with high-sensitivity troponin assays to identify those patients suitable for early discharge from the ED. In 2011, 27 chest pain risk scores were available for clinical use 10 with considerable variation in their uptake. It is therefore intuitive that the incorporation of chest pain risk scores with early high-sensitivity troponin testing may be a more acceptable option for clinicians. When included in chest pain risk scores, these clinical factors allow the clinician to estimate the risk of ACS even in the absence of high-sensitivity troponin elevations. 7,9 Those low cut-off value diagnostic strategies that have been published also fail to incorporate important risk-stratification factors gathered by the physician from clinical evaluation. Consequently, when urgent revascularization is added as an endpoint, the diagnostic performance of low-cut off values of high-sensitivity troponin diminishes to levels that may considerably limit clinical applicability. 2-5 However, by not including those patients who require urgent revascularization, this singular endpoint does not represent the full spectrum of clinically relevant acute coronary syndromes (ACS). 6-8 Those protocols employing low cut-off values for high-sensitivity troponin have consistently demonstrated a high diagnostic accuracy for acute myocardial infarction. 2-5 The second uses conventional cut-offs for high-sensitivity troponin assays in combination with chest pain risk scores. The first utilizes the ability of high-sensitivity troponin assays to measure low concentrations of troponin with cut-off values below the 99th percentile. Such rapid rule-out strategies may serve to substantially reduce hospital admissions and have major benefits for healthcare providers.Ĭurrently, rapid rule-out strategies may be broadly separated into two distinct categories. These patients may be suitable for early discharge from the ED with outpatient follow-up. Much of the recent focus within published literature has been on the use of high-sensitivity troponin assays in the identification of low-risk emergency department (ED) patients presenting with suspected cardiac chest pain who are at low risk of adverse cardiac events. 1 The high precision of these assays at very low concentrations, in comparison with contemporary assays, enables accurate quantification of troponin in most healthy people. High-sensitivity troponin assays have a coefficient of variation of 10% or less at the 99th percentile (the upper limit of the reference population) and are able to detect cardiac troponin in at least 50% of the reference population. ![]() High-sensitivity troponin assays have the potential to offer clinicians across the United States novel diagnostics strategies in the assessment of patients with chest pain and should be widely available subject to FDA approval. ![]()
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