Only had time to scan read so may have made a mistake but I think the paper
says the following:-

They did not suggest just Troponins, rather a triple test. TnI, CKMB and
myoglobin were used in conjunction with a risk stratification protocol not
dissimaler to the Manchester one. I think the public health guys and your
chief exec have either not read the paper, misunderstood it, or there is a
problem of information flow between what they really think and what has come
through to you.

The protocol described by Ng would probably result in MORE patients being
admitted as they kept all patients at risk of coronary artery disease for a
minimum of 12 hours (I suspect few hosps in UK do this for all their
potential CAD patients). The only ones they send home from the ED appear to
be those with negative ECGs, negative markers and they did not think they
had CAD anyway. It is not rocket science, though "probably" an improvement
over asking the opinion of the SHO for medicine on call :-)

At 90 mins TnI alone had a sensitivity of 86%, not enough for a rule out in
isolation.

13/400 patients returned with either MI or unstable angina requiring
admission.

I have attached the pathway, abstract below.

Abstract
Rapid, efficient, and accurate evaluation of chest pain patients in the
emergency department optimizes patient care from public health, economic,
and liability perspectives. To evaluate the performance of an accelerated
critical pathway for patients with suspected coronary ischemia that utilizes
clinical history, electrocardiographic findings, and triple cardiac marker
testing (cardiac troponin I [cTnI], myoglobin, and creatine kinase-MB
[CK-MB]), we performed an observational study of a chest pain critical
pathway in the setting of a large Emergency Department at the Veterans
Affairs Medical Center in 1,285 consecutive patients with signs and symptoms
of cardiac ischemia. The accelerated critical pathway for chest pain
evaluation was analyzed for: (1) accuracy in triaging of patients within 90
minutes of presentation, (2) sensitivity, specificity, positive predictive
value, and negative predictive value of cTnI, myoglobin, and CK-MB in
diagnosing acute myocardial infarction (MI) within 90 minutes, and (3)
impact on Coronary Care Unit (CCU) admissions. All MIs were diagnosed within
90 minutes of presentation (sensitivity 100%, specificity 94%, positive
predictive value 47%, negative predictive value 100%). CCU admissions
decreased by 40%. Ninety percent of patients with negative cardiac markers
and a negative electrocardiogram at 90 minutes were discharged home with 1
patient returning with an MI (0.2%) within the next 30 days. Thus, a simple,
inexpensive, yet aggressive critical pathway that utilizes high-risk
features from clinical history, electrocardiographic changes, and rapid
point-of-care testing of 3 cardiac markers allows for accurate triaging of
chest pain patients within 90 minutes of presenting to the emergency
department.



\Simon

NB. Isn't ATHENS access marvelous!

Simon Carley
SpR in Emergency Medicine
[log in to unmask]
Evidence based emergency medicine
http://www.bestbets.org
----- Original Message -----
From: "Brown, Ruth" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Thursday, October 17, 2002 3:52 PM


> A question about the use of Troponins
> Has anyone taken up the protocol suggested by Ng (Ng Siu Ming-AmJ Cardiol
> 2001 88-661-617 Pathway for Chest P.doc) where they suggest that troponins
> at 90 minutes will help send chest pains home safely. Our cardiologists
are
> very sceptical on the basis that very few patients were included in whom
it
> wasn't already clear it was not cardiac and the ones that troponin was
used
> on were very few. However, our Public Health colleagues are pressing us to
> use this, via our Chief Exec to solve the 4 hour problem!!!
>  Any comments?
> I have a scanned version of the paper if anyone wants it but very large so
> contact off list.
> thanks Ruth
>
> Ruth Brown
> Consultant in Emergency Medicine
> 0207 886 6574
>