The new Vancouver Chest Pain Rule using troponin as the only biomarker: an external validation study.
OBJECTIVE
To externally evaluate the accuracy of the new Vancouver Chest Pain Rule and to assess the diagnostic accuracy using either sensitive or highly sensitive troponin assays.


METHODS
Prospectively collected data from 2 emergency departments (EDs) in Australia and New Zealand were analysed. Based on the new Vancouver Chest Pain Rule, low-risk patients were identified using electrocardiogram results, cardiac history, nitrate use, age, pain characteristics and troponin results at 2 hours after presentation. The primary outcome was 30-day diagnosis of acute coronary syndrome (ACS), including acute myocardial infarction, and unstable angina. Sensitivity, specificity, positive predictive values and negative predictive values were calculated to assess the accuracy of the new Vancouver Chest Pain Rule using either sensitive or highly sensitive troponin assay results.


RESULTS
Of the 1635 patients, 20.4% had an ACS diagnosis at 30 days. Using the highly sensitive troponin assay, 212 (13.0%) patients were eligible for early discharge with 3 patients (1.4%) diagnosed with ACS. Sensitivity was 99.1% (95% CI 97.4-99.7), specificity was 16.1 (95% CI 14.2-18.2), positive predictive values was 23.3 (95% CI 21.1-25.5) and negative predictive values was 98.6 (95% CI 95.9-99.5). The diagnostic accuracy of the rule was similar using the sensitive troponin assay.


CONCLUSIONS
The new Vancouver Chest Pain Rule should be used for the identification of low risk patients presenting to EDs with symptoms of possible ACS, and will reduce the proportion of patients requiring lengthy assessment; however we recommend further outpatient investigation for coronary artery disease in patients identified as low risk.
Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Public Health, Queensland University of Technology, Brisbane, Australia; School of Medicine, The University of Queensland, Brisbane, Australia. Electronic address: louise_cullen@health.qld.gov.au.
Louise
L
Cullen
Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Public Health, Queensland University of Technology, Brisbane, Australia; School of Medicine, The University of Queensland, Brisbane, Australia.
Jaimi H
JH
Greenslade
Department of Emergency Medicine, Christchurch Hospital, New Zealand.
Martin
M
Than
Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Medicine, The University of Queensland, Brisbane, Australia.
Anthony F T
AF
Brown
School of Medicine, The University of Queensland, Brisbane, Australia; Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia.
Christopher J
CJ
Hammett
Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia.
Arvin
A
Lamanna
Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Medicine, The University of Queensland, Brisbane, Australia.
Dylan F
DF
Flaws
Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; School of Medicine, The University of Queensland, Brisbane, Australia.
Kevin
K
Chu
Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.
Lindsay F
LF
Fowles
School of Medicine, The University of Queensland, Brisbane, Australia; Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Australia.
William A
WA
Parsonage
D054058:Acute Coronary Syndrome / Q000097:blood / Q000150:complications / Q000175:diagnosis*; D000328:Adult; D000367:Age Factors; D000368:Aged; D015415:Biomarkers / Q000097:blood; D002637:Chest Pain / Q000209:etiology*; D003661:Decision Support Techniques; D004562:Electrocardiography; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D014336:Troponin / Q000097:blood*
D015415:Biomarkers; D014336:Troponin