title: Comparison of early biomarker strategies with the Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for risk stratification of emergency department patients with chest pain.
abstract: OBJECTIVE
  To compare cardiac risk stratification using a 0 and 2 h point-of-care (POC) cardiac troponin (cTn), 0 and 2 h POC multi-biomarkers against the 0 and 6 h laboratory cTn reference standard.
  
  
  METHODS
  A prospective observational study of ED patients presenting with chest pain was performed. Patients were risk stratified and treated as per the Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (HF-A/CS-ANZ) guidelines using the 0 and 6 h laboratory cTn (T6). Patients were further stratified using a 0 and 2 h POC cTn (T2) plus 0 and 2 h POC multi-biomarkers (cTn, creatine kinase-MB, myoglobin) (M2). The T6, T2 and M2 strategies were compared using the 30-day major adverse cardiac events as the primary outcome.
  
  
  RESULTS
  Seven hundred and four patients (median age 54 years, male 62.1%) were enrolled. Using the T6 reference standard, 2%, 61% and 37% were stratified as low, intermediate and high risk, respectively. The 30-day event rates were 0%, 3.5% and 28.6%, respectively. The T2 strategy stratified 1.5%, 57% and 41% as low, intermediate and high risk, respectively, with 30-day event rates of 0%, 4.2% and 24.8%, respectively. The M2 strategy resulted in significantly different risk distribution with 1%, 40% and 59% stratified as low, intermediate and high risk, respectively, with 30-day event rates of 0%, 3.9% and 18.8%, respectively.
  
  
  CONCLUSIONS
  Using a 2 h POC cTn-only biomarker strategy with the HF-A/CS-ANZ guidelines accurately identified a population at intermediate risk of 30-day events in whom further objective testing might be accelerated, allowing subsequent early discharge of the majority of this cohort. Within 2 h of presentation a high risk population could be identified in whom early management, including admission, was required.
authors.affiliation: Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia. louise_cullen@health.qld.gov.au
authors.forename: Louise
authors.initials: L
authors.lastname: Cullen
authors.forename: William A
authors.initials: WA
authors.lastname: Parsonage
authors.forename: Jaimi
authors.initials: J
authors.lastname: Greenslade
authors.forename: Arvin
authors.initials: A
authors.lastname: Lamanna
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Hammett
authors.forename: Martin
authors.initials: M
authors.lastname: Than
authors.forename: Jacobus P J
authors.initials: JP
authors.lastname: Ungerer
authors.forename: Kevin
authors.initials: K
authors.lastname: Chu
authors.forename: Shanen
authors.initials: S
authors.lastname: O'Kane
authors.forename: Anthony F T
authors.initials: AF
authors.lastname: Brown
mesh_terms: D000328:Adult; D000368:Aged; D044362:Australasia; D015415:Biomarkers / Q000097:blood; D002309:Cardiology / Q000592:standards; D002637:Chest Pain / Q000097:blood / Q000175:diagnosis*; D052279:Creatine Kinase, MB Form / Q000097:blood; D004635:Emergency Medicine / Q000379:methods*; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009211:Myoglobin / Q000097:blood; D019095:Point-of-Care Systems; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012308:Risk Management / Q000379:methods*; D012955:Societies, Medical / Q000592:standards; D014336:Troponin / Q000097:blood*
chemical_list: D015415:Biomarkers; D009211:Myoglobin; D014336:Troponin; D052279:Creatine Kinase, MB Form