Introduction The 2015 European Society of Cardiology (ESC) guidelines for investigation and management of non-ST elevation myocardial infarction (NSTEMI) discuss a ‘rule in/rule out’ (0h/1h) algorithm for the use of one-hour highly sensitive troponin assay (figure 1) (1). Following the application of this algorithm to several large cohorts, the negative predictive value for NSTEMI in patients assigned ‘rule out’ exceeded 98% according to these guidelines.
Aim The aim of this audit was to evaluate current practice of the assessment of cardiac sounding chest pain on the Acute Medical Unit (AMU) and to establish whether or not the introduction of highly sensitive one-hour troponin assay can shorten length of attendance and improve patient flow through the department.
Method Prospective data collection from October 2018 to December 2018. 99 patients presented to the AMU with cardiac sounding chest pain. Demographic data, ECG findings, troponin results, length of attendances and outcomes (admission, discharge and follow up) were captured.
Results 53% were male. Mean age was 63. 56 patients had initial troponin at presentation only. 12 patients had repeat troponin assays taken following 3 hours; 31 patients had repeat taken after 6 hours. Repeat blood tests for troponin were frequently taken at incorrect times. 9 patients had ischaemic changes on their initial ECG. Acute coronary syndrome was excluded in 88 patients; 26 patients were discharged with Emergency Access Cardiology clinic follow up for further investigation of chest pain. Of those patients who had repeat troponin tests, 77% of those could potentially have been discharged much sooner (avoiding some overnight stays) if the highly sensitive one-hour troponin assay was available (figure 2).
Conclusion This audit has highlighted several areas of disparity of standard practice in the assessment of chest pain on the AMU. We would like to undertake further work to improve standards. The recommendation of the one-hour troponin protocol suggested by ESC has the potential to significantly reduce length of attendance and improve patient flow and experience through the AMU.
Roffi M, Patrono C, Collet JP, Mueller C, Valgimili M, Andreoitti F, Bax J, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology, European Society of Cardiology, European Heart Journal January 2016;37(3):267–315.
Conflict of Interest None
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