The ASPECT trial

30 03 2011

Martin Than’s ASPECT trial was published last week in the Lancet. You can read the full article here…

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60310-3/abstract

And you can read my linked editorial here…

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60392-9/fulltext

There are also relevant news articles at these links…

http://www.theheart.org/article/1201195.do

http://www.familypracticenews.com/single-view/accelerated-protocol-identifies-lowest-risk-cardio-admissions/1c3a0729be.html

http://cardiobrief.org/2011/03/23/new-protocol-identifies-low-risk-chest-pain-patients/

This is a great study from 14 countries in the Asia-Pacific region. It relies on clever selection of a low risk population and serial biomarker testing over two hours to identify a proportion of emergency department patients with suspected cardiac chest pain that can be safely discharged.

The next big questions are (a) is it cost effective? (Steve Goodacre’s RATPAC trial will help to answer that when published in Academic Emergency Medicine in the near future); and (b) can we do better? (High sensitivity troponin assays, in particular, may improve sensitivity and enable a larger proportion of patient to be immediately discharged – but we’ll have to wait and see).

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2 responses

22 07 2013
UK med student

I’m not sure this is really clever selection of a low risk population. If a patient has a TIMI score of 0 I would expect a clinician to be able to discharge patients on basis of the clinical history. The advanced discharge protocol only identified 9.8% of patients as sufficiently low risk. I think common sense and clnical acumen would achieve a similar result.
UK Medical student

22 07 2013
richardbody

Thanks for your reply, UK Medical student. You raise quite an interesting point. All the evidence suggests that you can’t do this safely. We know that such a large proportion of our patients have atypical symptoms (http://www.ncbi.nlm.nih.gov/pubmed/20036454 and http://www.ncbi.nlm.nih.gov/pubmed/22738683, for example). We also know that a TIMI risk score of 0 doesn’t rule out an acute coronary syndrome (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2900327/). We also know that up to 6% of patients who are discharged from the ED after experiencing chest pain actually have AMI (http://www.ncbi.nlm.nih.gov/pubmed/10864545). So, it looks like an open and shut case for saying no, it wouldn’t be safe.

However, if you apply another filter (even if it has no intrinsic diagnostic value) you will always lower the number of patients who would be discharged and go on to experience an adverse event. As the number is relatively small in the group with a TIMI risk score of 0 anyway, it wouldn’t be too surprising if those with particularly atypical symptoms have a low risk of adverse events.

Whether you’d send home more patients than you could with a 2-hour troponin protocol and whether more of them would experience adverse events, we don’t know. Because of that, it’s far safer to use the protocols that have been validated. Even the 2-hour troponin protocols need more evidence just yet. So, as evidence-based medicine goes, we’re not in a position to be discharging patients with a TIMI risk score of 0 based on clinical judgement right now.

If you go to the MEMC conference in Marseille this September, I’m presenting an abstract that actually demonstrates the diagnostic value of clinical judgement in patients with suspected ACS. I can’t tell you the results just yet but they are interesting!

Rick

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