Working up low-risk chest pain - ADAPT and EDACS tie

Short Attention Span Summary

Which accelerated diagnostic pathway is best?
The EDACS and ADAPT accelerated diagnostic pathways (ADP) were compared in this RCT, and it was a tie.  EDACS found a higher percentage to be low risk than ADAPT.  But the number of early discharges at 6 hours was the same, as was the incidence of major adverse coronary events (MACE) at 30-days: 0% in each.  Based on this study, you could choose either pathway and get the same outcome.

A 65 year old with known CAD is low risk?
My problem with EDACS is that a person could still be considered "low risk" at age 65 who has known CAD.  Wait...what?  (HEART isn't much better... a >65 years old with positive troponin is "low risk?")

EDACS, ADAPT, HEART score, HEART pathway, HEARTS3?
Can you keep all these straight? I can't.  But Amal Mattu can.  See how Dr. Mattu works through low risk chest pain step-by-step using various pathways.

Spoon Feed
EDACS and ADAPT accelerated diagnostic pathways were the same with regard to early discharge at 6 hours and MACE. You can choose either one.


Abstract

Effectiveness of EDACS Versus ADAPT Accelerated Diagnostic Pathways for Chest Pain: A Pragmatic Randomized Controlled Trial Embedded Within Practice.

Ann Emerg Med. 2016 Jul;68(1):93-102.e1. doi: 10.1016/j.annemergmed.2016.01.001.

Ann Emerg Med. 2016 Jul;68(1):93-102.e1. doi: 10.1016/j.annemergmed.2016.01.001.

Effectiveness of EDACS Versus ADAPT Accelerated Diagnostic Pathways for Chest Pain: A Pragmatic Randomized Controlled Trial Embedded Within Practice.

Than MP1, Pickering JW2, Aldous SJ3, Cullen L4, Frampton CM5, Peacock WF6, Jaffe AS7, Goodacre SW8, Richards AM9, Ardagh MW3, Deely JM3, Florkowski CM2, George P2, Hamilton GJ3, Jardine DL2, Troughton RW2, van Wyk P3, Young JM3, Bannister L3, Lord SJ10.

Author information:

1Christchurch Hospital, Christchurch, New Zealand. Electronic address: martinthan@xtra.co.nz.

2Christchurch Hospital, Christchurch, New Zealand; University of Otago, Christchurch, New Zealand.

3Christchurch Hospital, Christchurch, New Zealand.

4Royal Brisbane and Women's Hospital, Herston, and the University of Technology, Brisbane, Queensland, Australia.

5University of Otago, Christchurch, New Zealand.

6Baylor College of Medicine, Houston, TX.

7Mayo Clinic, Rochester, MN.

8University of Sheffield, United Kingdom.

9University of Otago, Christchurch, New Zealand; National University of Singapore, Singapore.

10University of Notre Dame, Sydney Campus, and the National Health and Medical Research Council Clinical Trials, New South Wales, Australia.

Abstract

STUDY OBJECTIVE:

A 2-hour accelerated diagnostic pathway based on the Thrombolysis in Myocardial Infarction score, ECG, and troponin measures (ADAPT-ADP) increased early discharge of patients with suspected acute myocardial infarction presenting to the emergency department compared with standard care (from 11% to 19.3%). Observational studies suggest that an accelerated diagnostic pathway using the Emergency Department Assessment of Chest Pain Score (EDACS-ADP) may further increase this proportion. This trial tests for the existence and size of any beneficial effect of using the EDACS-ADP in routine clinical care.

METHODS:

This was a pragmatic randomized controlled trial of adults with suspected acute myocardial infarction, comparing the ADAPT-ADP and the EDACS-ADP. The primary outcome was the proportion of patients discharged to outpatient care within 6 hours of attendance, without subsequent major adverse cardiac event within 30 days.

RESULTS:

Five hundred fifty-eight patients were recruited, 279 in each arm. Sixty-six patients (11.8%) had a major adverse cardiac event within 30 days (ADAPT-ADP 29; EDACS-ADP 37); 11.1% more patients (95% confidence interval 2.8% to 19.4%) were identified as low risk in EDACS-ADP (41.6%) than in ADAPT-ADP (30.5%). No low-risk patients had a major adverse cardiac event within 30 days (0.0% [0.0% to 1.9%]). There was no difference in the primary outcome of proportion discharged within 6 hours (EDACS-ADP 32.3%; ADAPT-ADP 34.4%; difference -2.1% [-10.3% to 6.0%], P=.65).

CONCLUSION:

There was no difference in the proportion of patients discharged early despite more patients being classified as low risk by the EDACS-ADP than the ADAPT-ADP. Both accelerated diagnostic pathways are effective strategies for chest pain assessment and resulted in an increased rate of early discharges compared with previously reported rates.

Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

PMID: 26947800 [PubMed - in process]