title: Effectiveness of EDACS Versus ADAPT Accelerated Diagnostic Pathways for Chest Pain: A Pragmatic Randomized Controlled Trial Embedded Within Practice.
abstract: A 2-hour accelerated diagnostic pathway based on the Thrombolysis in Myocardial Infarction score, ECG, and troponin measures (ADAPT-ADP) increased early discharge of patients with suspected acute myocardial infarction presenting to the emergency department compared with standard care (from 11% to 19.3%). Observational studies suggest that an accelerated diagnostic pathway using the Emergency Department Assessment of Chest Pain Score (EDACS-ADP) may further increase this proportion. This trial tests for the existence and size of any beneficial effect of using the EDACS-ADP in routine clinical care.
  
  
  
  This was a pragmatic randomized controlled trial of adults with suspected acute myocardial infarction, comparing the ADAPT-ADP and the EDACS-ADP. The primary outcome was the proportion of patients discharged to outpatient care within 6 hours of attendance, without subsequent major adverse cardiac event within 30 days.
  
  
  
  Five hundred fifty-eight patients were recruited, 279 in each arm. Sixty-six patients (11.8%) had a major adverse cardiac event within 30 days (ADAPT-ADP 29; EDACS-ADP 37); 11.1% more patients (95% confidence interval 2.8% to 19.4%) were identified as low risk in EDACS-ADP (41.6%) than in ADAPT-ADP (30.5%). No low-risk patients had a major adverse cardiac event within 30 days (0.0% [0.0% to 1.9%]). There was no difference in the primary outcome of proportion discharged within 6 hours (EDACS-ADP 32.3%; ADAPT-ADP 34.4%; difference -2.1% [-10.3% to 6.0%], P=.65).
  
  
  
  There was no difference in the proportion of patients discharged early despite more patients being classified as low risk by the EDACS-ADP than the ADAPT-ADP. Both accelerated diagnostic pathways are effective strategies for chest pain assessment and resulted in an increased rate of early discharges compared with previously reported rates.
authors.affiliation: Christchurch Hospital, Christchurch, New Zealand. Electronic address: martinthan@xtra.co.nz.
authors.forename: Martin P
authors.initials: MP
authors.lastname: Than
authors.affiliation: Christchurch Hospital, Christchurch, New Zealand; University of Otago, Christchurch, New Zealand.
authors.forename: John W
authors.initials: JW
authors.lastname: Pickering
authors.affiliation: Christchurch Hospital, Christchurch, New Zealand.
authors.forename: Sally J
authors.initials: SJ
authors.lastname: Aldous
authors.affiliation: Royal Brisbane and Women's Hospital, Herston, and the University of Technology, Brisbane, Queensland, Australia.
authors.forename: Louise
authors.initials: L
authors.lastname: Cullen
authors.affiliation: University of Otago, Christchurch, New Zealand.
authors.forename: Christopher M A
authors.initials: CM
authors.lastname: Frampton
authors.affiliation: Baylor College of Medicine, Houston, TX.
authors.forename: W Frank
authors.initials: WF
authors.lastname: Peacock
authors.affiliation: Mayo Clinic, Rochester, MN.
authors.forename: Allan S
authors.initials: AS
authors.lastname: Jaffe
authors.affiliation: University of Sheffield, United Kingdom.
authors.forename: Steve W
authors.initials: SW
authors.lastname: Goodacre
authors.affiliation: University of Otago, Christchurch, New Zealand; National University of Singapore, Singapore.
authors.forename: A Mark
authors.initials: AM
authors.lastname: Richards
authors.affiliation: Christchurch Hospital, Christchurch, New Zealand.
authors.forename: Michael W
authors.initials: MW
authors.lastname: Ardagh
authors.affiliation: Christchurch Hospital, Christchurch, New Zealand.
authors.forename: Joanne M
authors.initials: JM
authors.lastname: Deely
authors.affiliation: Christchurch Hospital, Christchurch, New Zealand; University of Otago, Christchurch, New Zealand.
authors.forename: Chris M
authors.initials: CM
authors.lastname: Florkowski
authors.affiliation: Christchurch Hospital, Christchurch, New Zealand; University of Otago, Christchurch, New Zealand.
authors.forename: Peter
authors.initials: P
authors.lastname: George
authors.affiliation: Christchurch Hospital, Christchurch, New Zealand.
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Hamilton
authors.affiliation: Christchurch Hospital, Christchurch, New Zealand; University of Otago, Christchurch, New Zealand.
authors.forename: David L
authors.initials: DL
authors.lastname: Jardine
authors.affiliation: Christchurch Hospital, Christchurch, New Zealand; University of Otago, Christchurch, New Zealand.
authors.forename: Richard W
authors.initials: RW
authors.lastname: Troughton
authors.affiliation: Christchurch Hospital, Christchurch, New Zealand.
authors.forename: Pieter
authors.initials: P
authors.lastname: van Wyk
authors.affiliation: Christchurch Hospital, Christchurch, New Zealand.
authors.forename: Joanna M
authors.initials: JM
authors.lastname: Young
authors.affiliation: Christchurch Hospital, Christchurch, New Zealand.
authors.forename: Laura
authors.initials: L
authors.lastname: Bannister
authors.affiliation: University of Notre Dame, Sydney Campus, and the National Health and Medical Research Council Clinical Trials, New South Wales, Australia.
authors.forename: Sally J
authors.initials: SJ
authors.lastname: Lord
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002637:Chest Pain / Q000175:diagnosis* / Q000209:etiology; D019091:Critical Pathways; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis; D010351:Patient Discharge / Q000706:statistics & numerical data; D012307:Risk Factors; D013997:Time Factors; D055815:Young Adult