ACS:ED
Research type
Research Study
Full title
Acute Coronary Syndrome rule-out strategies in the Emergency Department: An observational evaluation of current UK practice & clinical effectiveness
IRAS ID
316000
Contact name
Edd Carlton
Contact email
Sponsor organisation
North Bristol NHS Trust
ISRCTN Number
ISRCTN00000000
Clinicaltrials.gov Identifier
Duration of Study in the UK
0 years, 0 months, 29 days
Research summary
Research Summary
Non-traumatic chest pain is one of the commonest reasons patients present to ED. Acute coronary syndrome (ACS) is a term used to describe a range of conditions associated with sudden, reduced blood flow to the heart, and is a medical emergency that can lead to severe illness or death. ACS can be challenging to confirm or exclude in the ED, and recent research has suggested that the judgement of a clinician is insufficient to confirm or exclude the diagnosis.
As a result, risk stratification strategies have been developed to facilitate objective and reproducible categorisation of a patient's likelihood of having ACS. These strategies vary but generally incorporate symptoms, history and examination findings alongside blood test and ECG findings. The aim of these strategies is two-fold; to ‘rule-in’ those who may be undergoing ACS and to identify low-risk patients who can be safely discharged home from the ED.
Discharging low risk patients has many benefits, including reducing the number of investigations patients receive, reduced length of stay in the ED and avoiding a hospital admission. Conversely, inadvertent discharge of patients who are undergoing ACS can result in severe illness or death for these patients. All risk-stratification tools must balance diagnostic accuracy against safe discharge.
Although several studies have compared the clinical effectiveness of risk scores within the ED, the real-world variation in the use and adherence to these pathways is poorly understood. In addition, there is limited data on the comparative clinical effectiveness of these pathways, or their diagnostic accuracy outside a research environment and the prevalence of alternative diagnoses in those presenting with suspected cardiac chest pain. To understand the size of the diagnostic dilemma of chest pain, we must establish the incidence of ACS and alternative diagnoses in those presenting to the ED with suspected cardiac chest pain.
Summary of Results
This study, entitled ' Acute Coronary Syndrome rule-out strategies in the Emergency Department: An observational evaluation of current UK practice & clinical effectiveness ' was carried out by the Royal College of Emergency Medicine's Trainee Emergency Research Network and funded by the Royal College of Emergency Medicine. The study took place in 94 emergency departments (EDs) across the UK in March and April of 2023.
Chest pain is a common reason for patients to present to the emergency department. Over the past decade the pathways and protocols used in patients presenting with chest pain have been developed to reduce the time spent in the ED for those who can be safely discharged after a heart attack is ruled out. These pathways use a blood test called high sensitivity troponin. Before this study, there was little research describing what effect these pathways have on the length of time patients spend in the ED. This study asked these questions: Which pathways for ruling out a heart attack are in use in UK EDs? What impact do these pathways have on patient's length of stay in the ED? How many patients presenting to the ED with chest pain meet diagnostic criteria for a heart attack?
The study enrolled adult patients presenting to the ED with chest pain triggering testing for a possible heart attack. There were no changes to the patients' investigations or treatments as part of the study. Local study teams collected information on the demographics of the patients, their test results, how long they spent in the ED and their diagnosis. This information was uploaded in an anonymized form to an online study database.
The results of the study showed that chest pain accounted for just over 5% of all adult ED attendances. Numerous chest pain assessment pathways were seen to be in use across the UK with most EDs are now using what are known as 'rapid rule-out' pathways. Despite this patients spend a similar amount of time in the ED regardless of which hospital they present to and which pathway is in use. The average time spent in the ED for patients discharged home with a heart attack ruled out was 5.5 hours with little difference between pathways. Just over 15% of patients presenting with chest pain met diagnostic criteria for a heart attack.
Future research in this area should focus on why these 'rapid rule-out' pathways are not resulting in shorter ED visits and how they can be implemented to achieve this. The main issue is likely to be how busy and crowded UK EDs currently are.
REC name
Wales REC 3
REC reference
22/WA/0247
Date of REC Opinion
29 Sep 2022
REC opinion
Further Information Favourable Opinion