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

• Published in: Annals of emergency medicine Vol. 68; no. 1; pp. 93 - 102.e1
• Main Authors: Than, Martin P., MBBS, Pickering, John W., PhD, Aldous, Sally J., MBChB, PhD, Cullen, Louise, MBBS, PhD, Frampton, Christopher M.A., PhD, Peacock, W. Frank, MD, Jaffe, Allan S., MD, Goodacre, Steve W., PhD, Richards, A. Mark, MD, PhD, Ardagh, Michael W., PhD, Deely, Joanne M., PhD, Florkowski, Chris M., MBBS, MD, George, Peter, MBBS, Hamilton, Gregory J., PhD, Jardine, David L., MBChB, DCH, Troughton, Richard W., MBChB, PhD, van Wyk, Pieter, MBChB, Young, Joanna M., PhD, Bannister, Laura, MBBS, Lord, Sally J., MBBS
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-07-2016
• Subjects: Adolescent; Adult; Aged; Aged, 80 and over; Chest Pain - diagnosis; Chest Pain - etiology; Critical Pathways; Emergency; Emergency Service, Hospital; Female; Humans; Male; Middle Aged; Myocardial Infarction - diagnosis; Patient Discharge - statistics & numerical data; Risk Factors; Time Factors; Young Adult
• ISSN: 0196-0644; 1097-6760
• DOI: 10.1016/j.annemergmed.2016.01.001

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.