Journal Club Handout Template - Goldilocksthedoc
1/21/16 Journal Club Handout
|Background and Overview |
|Article Title/Citation |Identifying 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. 635–645.e1 |
|Study objectives/purpose |Compare how well 5 established AMI risk scores identify patients with suspected ACS who are suitable for discharge|
|(and research hypothesis if applicable) |after 1 high sensitivity troponin result. |
|Brief Background |Chest pain (CP) is a very common complaint in the ED. |
|(why issue is important, summary of previous |Of the over 6 million people who complain of CP in the ED 15-25% will be diagnosed with acute coronary syndrome |
|literature) |(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 interval |
|Funding Sources |College of Emergency Medicine of the UK |
| |Bournemouth University |
| |Dr. Carlton received funding from Abbott |
| |Dr. Greaves received funding from AstraZeneca and Takeda UK |
|Methods |
|Patient selection and |Sample Size: 959 |
|Enrollment (inclusion/exclusion criteria, sample |Inclusion criteria: |
|size etc.) |( 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 available |
| |
|Study design and |Type: Prospective cohort study (planned post hoc analysis) |
|Methodology (type of trial, randomization, |Setting: 1 UK district general hospital |
|blinding, Controls, study groups, Length of |Study Groups: Troponin-T vs. Troponin-I |
|study, etc.) |Length of Study: July 2012 to August 2013 |
|Interventions |Troponin-I |
|(if applicable) |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 Rule |
|Outcome measures/Endpoints |Primary Endpoint: Fatal or non-fatal AMI occurring within 30 days of hospital attendance (change in trop, EKG |
| |changes, or imaging evidence of ischemia) |
|Statistical analysis |Chi squared analysis |
| |Thresholds that needed to be met: |
| |Sensitivity ( 98% |
| |NPV ( 99.5% |
| |( 30% identified as suitable to discharge |
|Results |
|Enrollment & Baseline |See table 1 |
|Characteristics | |
|Summary of primary & secondary outcomes |AMI in 30 days: 8.2% in troponin-T group |
|(including subgroup analysis, etc. include both |7.6% in troponin-I group |
|efficacy and safety parameters) |Met thresholds: |
| |No combo of 1 risk score with either troponin |
| |TIMI ( 1 + Goldman ( 1 + troponin-T |
| |TIMI = 0 + HEART ( 3 + troponin-I |
|Discussion and Conclusions |
|Brief summary of authors’ main discussion points |Several 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 scores |
|Author’s conclusions |May be possible to identify low risk patients using a single high sensitivity troponin at presentation |
|Study strengths |Use of established, validated risk scoring systems |
| |Large sample size |
|Study limits, weakness, |Low prevalence of primary endpoint (8%) |
|Potentials for bias, etc. |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 physician’s used the Goldman score to eval patients which may explain superior diagnostic performance |
| |Doesn’t take into acct clinical gestalt (makes 100% sensitivity possible) |
|Applicability & impact |Currently, troponin is repeated in most EDs at 3 hours after presentation with good confidence. |
|On healthcare providers |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 don’t take clinician gestalt into account. |
| |Clinical practice is unlikely to change because of these results. |
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