Going to the Emergency Department with chest pain no longer means an almost certain night in hospital. Friday saw the publication online of our randomised controlled trial comparing two different strategies to rapidly rule-out heart attacks in people who present with chest pain to hospitals. Here’s a précis:
What’s the problem?
- Chest pain is common – 10% or so of presentations to ED are for chest pain.
- Heart attacks are not so common – only ~10-15% in NZ (and less overseas*) actually have a heart attack.
- It is devilishly difficult for most chest pain to rapidly rule out the possibility of a heart attack.
- Consequently, most people get admitted to hospital (in 2007 93% of those presenting with chest pain).
But – led by Dr Martin Than in Christchurch and an international group including Dr Louise Cullen in Brisbane – a series of observational studies and one randomised control trial have resulted in a gradual increase in the proportion discharged. The trial was the first of its kind, it compared standard practice at assessing chest pain to a purpose built accelerated diagnostic pathway (ADP), which we called ADAPT. In that study 11% of patients in the standard practice (control) arm and 19.3% in the ADAPT ADP arm (experimental arm) were discharged home from ED within 6 hours. A great improvement which led to that ADP being adopted in Christchurch hospital.
So why another study?
Two reasons: First, 19% still means that there are many patients being admitted who potentially don’t need to be in hospital. Second, the ADP was based around a risk assessment tool designed to rule-in heart attacks rather than rule-out. In the meantime, the team had constructed a purpose build risk assessment tool that in observational studies looked like it could rule out 40-50% of patients.
What is the study just published?
The world’s second randomised controlled trial of assessment of chest pain compared the ADAPT ADP in use (now the control arm) with a new ADP based on the new Emergency Department Assessment of Chest pain Score (EDACS)[the experimental arm]. The only difference between the two arms of the study was the risk assessment tool used. The tool gave a risk score. Patients with a low score, no unusual electrical activity in the heart, and no elevated heart muscle injury proteins in either of two blood samples measured 2 hours apart, were considered low risk.
An important aspect of the study was that it was pragmatic. This means that the doctors didn’t have to follow the ADP and could decide to send a patient home, or not send them home, based on any factors they thought clinically relevant. This makes it very tough to run a trial, but it makes the trial more “real life.”
What were the results?
558 patients were recruited. They all volunteered and are marvellous people. I love volunteers.
The primary outcome was the proportion of patients safely discharged home within 6 hours. We assessed safety by looking at all medical events that happened to a patients over 30 days to check to see if any patients discharged home had a major cardiac event that could potentially have been picked up in the ED.
34% of the control arm and 32% of the experimental arm were discharged within 6 hours. In other words, there was no difference in early discharge rates between the two arms. The surprising feature of this is that between 2012/3 (when the first trial was run) and 2014/15 the proportion of patients the first ADP ruled out increased from 19% to 34%. This was unexpected, but pleasing. There were no safety concerns with any patients.
The secondary outcome was simply the proportion each arm of the study classified as low risk (ie not considering whether this led to early discharge or not). The control (ADAPT ADP) classified 31% and the experimental (EDACS ADP) 42%. This was a real and meaningful difference which suggests that there is “room for improvement” in early discharge rates as the clinicians become more familiar with the EDACS ADP.
Since 2007 in Christchurch hospital over three times more patients who present with chest pain can be reassured from within the ED that they are not having a heart attack and discharged home (see the infographic).
What was your role?
My role: I managed aspects of the data collection for the later 2/3rds of the patients recruited, did the statistical analysis and co-wrote the manuscript. In reality, there were a lot of people involved, not least of whom were the wonderful research nurses and database manager who did a lot of the “grunt work”.
Over the last year all EDs in New Zealand have implemented or in the process of implementing an accelerated diagnostic pathway. The majority have chosen to use the EDACS pathway. I am part of a team nationwide helping implement these pathways and monitor their efficacy and safety.
This study was funded by the Health Research Committee of New Zealand. The work was carried out with the collaboration or the University of Otago Christchurch, Christchurch Heart Institute, and the Canterbury District Health Board Emergency Department, Cardiology Department, General Medicine, and Canterbury Health Laboratories. My salary is provided through a Senior Research Fellowship in Acute Care funded Canterbury Medical Research Foundation, Canterbury District Health Board and the Emergency Care Foundation.
*Not because we have more heart attacks, just an efficient and well funded primary care sector that keeps the very low risk patients out of the ED.
**Featured Image: Creative Commons Share-Alike 3.0 http://tcsmoking.wikispaces.com/heart%20attack