FAQS: Chest Pain Accelerated Diagnostic Pathways
Date:
Prepared by:
22 September 2014
Associate Professor John Pickering and Dr Martin Than, Christchurch Hospital.
1. What are the key components of an ACS clinical framework incorporating an ADP?
 A clear clinical pathway documentation process.
 A structured and reproducible process of ACS risk stratification (e.g. a clinical score).
 Guidance for consistency of sampling time-points for performing cTn and ECG testing
(e.g. on arrival and after a further specified timepoint(s)).
 Guidance about how to combine clinical risk stratification, and ECG and troponin
testing with a structure on how to guide patient management (accelerated discharge
using ADP, discharge, admission and further investigations).
 Guidance and timeframes for performing follow-up testing for low risk patients; e.g.
stress testing.
 Guidance for selection of patients for telemetry and removal from telemetry (e.g.
nurse initiated removal from telemetry for symptom free, non-high risk patients
following initially normal vital signs, ECG and troponin).
 A clear pathway for further investigations and interventions for patients at high clinical
risk and with positive investigation results.
 Clear discharge planning, which includes patient education and lifestyle modification
advice.
2. What is the best timing for the second troponin?
 Christchurch has been using two hours post the on admission troponin.
 From a pragmatic perspective in order to meet the six hour target, the second
troponin must be early enough for the lab to turn it around and for the clinician to
review it. The lab turn-around time is crucial and must be taken into account when
considering if a later time than 2 hours is to be used.
3. What is the best timing for the later troponin for the intermediate (Not low) risk
group?
 For the past 2 years Christchurch has been using 6 hours from first or worst
pain. This has worked well. 6 hours is standard in European and USA guidelines.
4. Where can I find information about troponin assay characteristics?
http://www.ifcc.org/media/245202/IFCC Troponin I and T (ng_L units)_ update December
2013.pdf
5. Where can I find information about risk scores?
TIMI
Antman, E. M., Cohen, M., Bernink, P. J. L. M., McCabe, C. H., Horacek, T., Papuchis, G., et
al. (2000). The TIMI Risk Score for Unstable Angina/Non–ST Elevation MI. JAMA : the
Journal of the American Medical Association, 284(7), 835. doi:10.1001/jama.284.7.835
Than, M. P., Aldous, S., Lord, S. J., Goodacre, S., Frampton, C. M. A., Troughton, R., et al.
(2014). A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency
department: a randomized clinical trial. JAMA Internal Medicine, 174(1), 51–58.
doi:10.1001/jamainternmed.2013.11362
Online calculator: http://www.mdcalc.com/timi-risk-score-for-uanstemi/
EDACS
Than, M. P., Flaws, D., Sanders, S., Doust, J., Glasziou, P., Kline, J., et al. (2014).
Development and validation of the Emergency Department Assessment of Chest pain Score
and 2 h accelerated diagnostic protocol. Emergency Medicine Australasia : EMA, 26(1), 34–
44. doi:10.1111/1742-6723.12164
Online calculator: http://edaculator.adelaideemergencyphysicians.com
GRACE
Eagle, K. A., Lim, M. J., Dabbous, O. H., Pieper, K. S., Goldberg, R. J., van de Werf, F., et al.
(2004). A validated prediction model for all forms of acute coronary syndrome: estimating the
risk of 6-month postdischarge death in an international registry. JAMA : the Journal of the
American Medical Association, 291(22), 2727–2733. doi:10.1001/jama.291.22.2727
Online calculator: http://www.mdcalc.com/grace-acs-risk-and-mortality-calculator/
HEART
Six, A. J., Backus, B. E., & Kelder, J. C. (2008). Chest pain in the emergency room: value of
the HEART score. Netherlands Heart Journal : Monthly Journal of the Netherlands Society of
Cardiology and the Netherlands Heart Foundation, 16(6), 191–196.
Online calculator: http://www.mdcalc.com/heart-score-for-major-cardiac-events/
Risk Score Comparison
Cullen, L., Greenslade, J., Hammett, C. J., Brown, A. F. T., Chew, D. P., Bilesky, J., et al.
(2013). Comparison of Three Risk Stratification Rules for Predicting Patients With Acute
Coronary Syndrome Presenting to an Australian Emergency Department. Heart, Lung &
Circulation, 22(10), 844–851. doi:10.1016/j.hlc.2013.03.074
Compares TIMI, GRACE and the Heart Foundation of Australia/Cardiac Society of Australia
and New Zealand guidelines.
6. What issues/barriers are there in setting up a chest pain adap?
EXAMPLES OF POTENTIAL BARRIERS/ISSUES
Having the barriers identified up-front is important to the successful implementation of any change.
timeframes - inadequate planning and elbow room
inadequate time - no extra time allocated to local participants
bringing dr colleagues on board = convince via data, concepts, research, personal touch, MoH
target, money, time
bringing nurse colleagues on board - need nurse champions
changing clinical cultures
reassuring pts and staff
administrative issues - printing forms, collecting forms, altering forms
lab engagement - not relying on single person
short term work creation vs long term work improvement
to isolate study as 'lone event' vs incorporate into widespread change picture
language issues - we use interpreters daily
knee jerk reactions
driving demand vs reducing demand - no resource to do more?!
turnaround time for lab samples
possible shift in workload between departments
possible increase in use of treadmills
coordinate changes to documentation
patient education and advice
which department is in charge
choice of risk stratification score