Effectiveness of EDACS Versus ADAPT Accelerated Diagnostic Pathways for Chest Pain: A Pragmatic Randomized Controlled Trial Embedded Within Practice - 24/06/16
, John W. Pickering, PhD a, b, Sally J. Aldous, MBChB, PhD a, Louise Cullen, MBBS, PhD c, Christopher M.A. Frampton, PhD b, W. Frank Peacock, MD d, Allan S. Jaffe, MD e, Steve W. Goodacre, PhD f, A. Mark Richards, MD, PhD b, g, Michael W. Ardagh, PhD a, Joanne M. Deely, PhD a, Chris M. Florkowski, MBBS, MD a, b, Peter George, MBBS a, b, Gregory J. Hamilton, PhD a, David L. Jardine, MBChB, DCH a, b, Richard W. Troughton, MBChB, PhD a, b, Pieter van Wyk, MBChB a, Joanna M. Young, PhD a, Laura Bannister, MBBS a, Sally J. Lord, MBBS hAbstract |
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.
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| Please see page 94 for the Editor’s Capsule Summary of this article. |
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| Supervising editor: Judd E. Hollander, MD |
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| Author contributions: MPT, SJA, LC, CMAF, WFP, ASJ, SWG, AMR, MAW, JMD, CMF, PG, GJH, DLJ, RWT, and SJL contributed to the study design; MPT, JWP, SJA, LC, CMAF, WFP, ASJ, SWG, AMR, MWA, CMF, PG, RWT, PvW, JMY, LB, and SJL contributed to the analysis and interpretation. MPT, JWP, LC, EP, JMD, and SJL contributed to the drafting of the article. All authors provided critical revision of the article. MPT takes responsibility for the paper as a whole. |
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| Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. The trial was funded by the Health Research Council of New Zealand (grant 12-249). |
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| Trial registration number: ACTRN12613000745741 |
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| A podcast for this article is available at www.annemergmed.com. |
Vol 68 - N° 1
P. 93 - juillet 2016 Retour au numéro
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