Is it safe to discharge patients from accident and emergency using a rapid point of care Triple Cardiac Marker test to rule out acute coronary syndrome in low to intermediate risk patients presenting with chest pain?

PURPOSE

To determine whether patients presenting with chest pain who are at low to intermediate risk for ACS can safely be discharged from Accident and Emergency using Triple Cardiac Marker [TCM] [CK-MB, myoglobin, troponin I] without increasing risk and cost effective use of coronary care facilities.

METHODS

Retrospective review of consecutive patients presented to A&E between Dec 2003 and July 2004 was performed and these patients were prospectively followed for six months for future coronary events and hospital admissions. A total of 325 patients presented to A&E with chest pain that were at low to intermediate risk for ACS. Paired TCM and ECGs were performed 2 h apart and the results were used to determine whether hospital admission was required. Follow up data was collected from hospital records, hospital database, GPS and patient interviews.

RESULTS

325 consecutive patients [225 men, 100 women; aged 18-97 years, median-68 years] were included in the study. Paired TCM was negative in 100 patients [30%] and they were discharged from A&E. The re-admission rate for this group of patients was 1% with ACS and no deaths from cardiac cause at six months. 36 [11%] had single TCM negative and were sent home with 3% re-admission rate with ACS and no death at six months. Subgroup analysis shows sensitivity and specificity of 85.7% and 96.5% respectively for TCM to diagnose ACS in this setting.

CONCLUSION

Almost one third of patients who presented with chest pain and low to intermediate probability of ACS were safely discharged from A&E following paired negative TCM. Six month re-admission rate with ACS in this group of patients was only 1% with no death. Therefore paired TCM can be used to safely discharge this group of patients. This marker has the potential to significantly reduce hospital admissions.