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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