WikEM - User contributions [en]

EBQ talk:ADAPT Trial 2-Hour Troponin Rule Out

2017-03-23T05:12:02Z

Orinoco w: Created page with "TIMI < 0 - guys, you cannot have TIMI < 0"

TIMI < 0
- guys, you cannot have TIMI < 0

EBQ:ADAPT Trial 2-Hour Troponin Rule Out

2017-03-23T05:11:30Z

Orinoco w: /* Major Points */

{{JC info
| title= 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial
| abbreviation=ADAPT
| expansion=Accelerated Diagnostic Protocol
| published=2012
| author=Than M.
| journal=Journal of the American College of Cardiology
| year=2012
| volume= 59
| issue=23
| pages=2091-2098
| pmid=22578923
| fulltexturl= http://content.onlinejacc.org/article.aspx?articleid=1216447
| pdfurl= http://content.onlinejacc.org/data/Journals/JAC/24307/02035.pdf
| status =Complete
}}

==Clinical Question==
'''Can an accelerated diagnostic protocol (ADP) for chest pain be used to identify low-risk patients suitable for discharge with close followup?'''

==Conclusion==
'''An accelerated diagnostic protocol of 2 negative troponins, a TIMI score = 0 and no ischemic changes on ECG. can successfully identify low risk chest pain patients for discharge from the emergency department and decrease observational stay.'''

==Major Points==
*The ADP relies on a combination of 2 negative troponins, a [[ACS_-_Risk_Stratification#TIMI_Risk_Stratification_Score|TIMI]] score = 0 and no ischemic changes on ECG.
*The ADP successfully classifies patients as low risk and has a sensitivity of 99.7 for identifying patients who will have Major Adverse Cardiac Events (MACE)
*Patients who are not low risk according to the ADP should continue to be managed with existing clinical care that involves extended observation or admission.
*Patients with a negative troponin at 0 hours and 2 hrs, a TIMI=0 and no ischemic ECG changes can be discharged with close cardiac followup.

'''All parameters had to be negative for the ADP to be considered negative and for the patient to be identified as low-risk
#cTnI level at 0 and 2 h below institutional cutoff for an elevated troponin concentration
#No new ischemic changes on the initial ECG 3. TIMI score = 0'''

{{TIMI Score}}

==Design==
*Prospective observational validation study
*The study population was from Brisbane, Australia and Christchurch, New Zealand. These patients were from 2 of the 14 sites participating in the [[EBQ:ASPECT Trial|ASPECT Trial]].
*Although using the same patients, the ADAPT trial was approved at the initiation of the [[EBQ:ASPECT Trial|ASPECT Trial]].
*Patients were enrolled consecutively between November 2007 and February 2011

==Population==
===Inclusion Criteria===
*Age >18 years of age, with at least 5 min of symptoms consistent with ACS
*The attending physician planned to perform serial cTn tests

===Exclusion Criteria===
*ST-segment elevation myocardial infarction (STEMI)
*Cause other than ACS for the symptoms (e.g., examination findings of varicella zoster)
*Inability to provide informed consent
*Staff considered recruitment to be inappropriate (e.g., receiving palliative treatment), transfer from another hospital, pregnancy, previous enrollment, or inability to be contacted after discharge.
===Baseline Characteristics===
*Age: 60.4
*Male: 60.0%
*White Race: 90%
*Risk Factors
**HTN: 52.1%
**DM: 14.4
**Dyslipidemia: 51

==Interventions==
Patients were either stratified to the be negative or positive for the accelerated diagnostic protocol and were then followed for 30 days with major cardiac events recorded.

==Outcomes==
===Primary Outcomes===
*No patients were lost at 30-day followup
*392 patients were classified as ADP negative and only 1 had a major cardiac event
**This patient 12 hour after evaluation had an MI requiring stenting

;Major Adverse Cardiac Events (MACE): (n=350)
#Non–STEMI (273)
#STEMI (25)
#Emergency revascularization (26)
#Cardiovascular death (8)
#Ventricular arrhythmia (6)
#Cardiac arrest (3)
#Cardiogenic shock (4)
#High atrioventricular block (5)
===Secondary Outcomes===
*Subgroup analysis classified the individual diagnostic parameters (TIMI score, ECG, and 2 sets of troponins) in various combinations identified in the following table.
*TIMI score and ECG without troponins failed to identify 5 patients with major cardiac event

==Subgroup Analysis==
Diagnostic qualities to predict adverse major adverse cardiac events
{|class="wikitable"
| align="center" style="background:#f0f0f0;"|'''Test Characteristic'''
| align="center" style="background:#f0f0f0;"|'''ECG'''
| align="center" style="background:#f0f0f0;"|'''Troponin'''
| align="center" style="background:#f0f0f0;"|'''Troponin & ECG'''
| align="center" style="background:#f0f0f0;"|'''TIMI & ECG'''
| align="center" style="background:#f0f0f0;"|'''ADP (ECG +TIMI + Troponin)'''
|-
| Sensitivity||24.5%||87.4%||89.1%||98.3%||99.7%
|-
| Specificity||88.5%||92.6%||82.6%||23.5%||23.4%
|-
| Negative Likelihood Ratio||0.85||0.14||0.13||0.07||0.01
|-
| Positive Likelihood Ratio||2.12||11.79||5.12||1.29||1.3
|}

==Criticisms and Further Discussion==
*The pretest probability for MACE was 15.3% which may differ for many readers depending on their patient population. Also this protocol has not been validated at any outside institution.

*The study uses the used Troponin I (cTnI) not the high sensitivity version (hs-cTnI).<ref>http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3627711/</ref> If using this troponin the study can directly apply to certain EDs. However if using the high sensitivity version then more positives are likely and the the patients with negative rapid diagnostics protocols will be less and admission rates may be higher

*The TIMI score has questionable application to an acute ED population since it was developed for inpatients<ref name="commentary">Hess, Erik et al. Evaluation of Patients With Possible Cardiac Chest Pain - A Way Out of the Jungle. J Am Coll Cardiol. 2012;59(23):2099-2100. doi:10.1016/j.jacc.2012.03.021 [http://content.onlinejacc.org/data/Journals/JAC/24307/03021.pdf PDF]</ref>

*74% of patients had a followup provocative study so this protocol should not be initiated if proper outpatient followup cannot be imitated<ref name="commentary"></ref>

*With a high combined sensitivity it offers promise for ruling out MACE but the low specificity may actually result in too stringent a criteria with unnecessary chest pain admissions.

==Funding==
Christchurch Cardio-Endocrine Research Group and the Queensland Emergency Medicine Research Foundation with (20%) contributions from industry (Abbott and Alere). Drs. Than, Cullen, and Parsonage, and Prof. Richards and Prof. Peacock had paid travel, accommodations, consulting fees, and honoraria from Abbott.

==Sources==
<references/>

[[Category:EBQ]][[Category:Cardiology]]

EBQ:ADAPT Trial 2-Hour Troponin Rule Out

2017-03-23T05:10:35Z

Orinoco w: /* Conclusion */

{{JC info
| title= 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: the ADAPT trial
| abbreviation=ADAPT
| expansion=Accelerated Diagnostic Protocol
| published=2012
| author=Than M.
| journal=Journal of the American College of Cardiology
| year=2012
| volume= 59
| issue=23
| pages=2091-2098
| pmid=22578923
| fulltexturl= http://content.onlinejacc.org/article.aspx?articleid=1216447
| pdfurl= http://content.onlinejacc.org/data/Journals/JAC/24307/02035.pdf
| status =Complete
}}

==Clinical Question==
'''Can an accelerated diagnostic protocol (ADP) for chest pain be used to identify low-risk patients suitable for discharge with close followup?'''

==Conclusion==
'''An accelerated diagnostic protocol of 2 negative troponins, a TIMI score = 0 and no ischemic changes on ECG. can successfully identify low risk chest pain patients for discharge from the emergency department and decrease observational stay.'''

==Major Points==
*The ADP relies on a combination of 2 negative troponins, a [[ACS_-_Risk_Stratification#TIMI_Risk_Stratification_Score|TIMI]] score < 0 and no ischemic changes on ECG.
*The ADP successfully classifies patients as low risk and has a sensitivity of 99.7 for identifying patients who will have Major Adverse Cardiac Events (MACE)
*Patients who are not low risk according to the ADP should continue to be managed with existing clinical care that involves extended observation or admission.
*Patients with a negative troponin at 0 hours and 2 hrs, a TIMI<0 and no ischemic ECG changes can be discharged with close cardiac followup.

'''All parameters had to be negative for the ADP to be considered negative and for the patient to be identified as low-risk
#cTnI level at 0 and 2 h below institutional cutoff for an elevated troponin concentration
#No new ischemic changes on the initial ECG 3. TIMI score < 0'''

{{TIMI Score}}

==Design==
*Prospective observational validation study
*The study population was from Brisbane, Australia and Christchurch, New Zealand. These patients were from 2 of the 14 sites participating in the [[EBQ:ASPECT Trial|ASPECT Trial]].
*Although using the same patients, the ADAPT trial was approved at the initiation of the [[EBQ:ASPECT Trial|ASPECT Trial]].
*Patients were enrolled consecutively between November 2007 and February 2011

==Population==
===Inclusion Criteria===
*Age >18 years of age, with at least 5 min of symptoms consistent with ACS
*The attending physician planned to perform serial cTn tests

===Exclusion Criteria===
*ST-segment elevation myocardial infarction (STEMI)
*Cause other than ACS for the symptoms (e.g., examination findings of varicella zoster)
*Inability to provide informed consent
*Staff considered recruitment to be inappropriate (e.g., receiving palliative treatment), transfer from another hospital, pregnancy, previous enrollment, or inability to be contacted after discharge.
===Baseline Characteristics===
*Age: 60.4
*Male: 60.0%
*White Race: 90%
*Risk Factors
**HTN: 52.1%
**DM: 14.4
**Dyslipidemia: 51

==Interventions==
Patients were either stratified to the be negative or positive for the accelerated diagnostic protocol and were then followed for 30 days with major cardiac events recorded.

==Outcomes==
===Primary Outcomes===
*No patients were lost at 30-day followup
*392 patients were classified as ADP negative and only 1 had a major cardiac event
**This patient 12 hour after evaluation had an MI requiring stenting

;Major Adverse Cardiac Events (MACE): (n=350)
#Non–STEMI (273)
#STEMI (25)
#Emergency revascularization (26)
#Cardiovascular death (8)
#Ventricular arrhythmia (6)
#Cardiac arrest (3)
#Cardiogenic shock (4)
#High atrioventricular block (5)
===Secondary Outcomes===
*Subgroup analysis classified the individual diagnostic parameters (TIMI score, ECG, and 2 sets of troponins) in various combinations identified in the following table.
*TIMI score and ECG without troponins failed to identify 5 patients with major cardiac event

==Subgroup Analysis==
Diagnostic qualities to predict adverse major adverse cardiac events
{|class="wikitable"
| align="center" style="background:#f0f0f0;"|'''Test Characteristic'''
| align="center" style="background:#f0f0f0;"|'''ECG'''
| align="center" style="background:#f0f0f0;"|'''Troponin'''
| align="center" style="background:#f0f0f0;"|'''Troponin & ECG'''
| align="center" style="background:#f0f0f0;"|'''TIMI & ECG'''
| align="center" style="background:#f0f0f0;"|'''ADP (ECG +TIMI + Troponin)'''
|-
| Sensitivity||24.5%||87.4%||89.1%||98.3%||99.7%
|-
| Specificity||88.5%||92.6%||82.6%||23.5%||23.4%
|-
| Negative Likelihood Ratio||0.85||0.14||0.13||0.07||0.01
|-
| Positive Likelihood Ratio||2.12||11.79||5.12||1.29||1.3
|}

==Criticisms and Further Discussion==
*The pretest probability for MACE was 15.3% which may differ for many readers depending on their patient population. Also this protocol has not been validated at any outside institution.

*The study uses the used Troponin I (cTnI) not the high sensitivity version (hs-cTnI).<ref>http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3627711/</ref> If using this troponin the study can directly apply to certain EDs. However if using the high sensitivity version then more positives are likely and the the patients with negative rapid diagnostics protocols will be less and admission rates may be higher

*The TIMI score has questionable application to an acute ED population since it was developed for inpatients<ref name="commentary">Hess, Erik et al. Evaluation of Patients With Possible Cardiac Chest Pain - A Way Out of the Jungle. J Am Coll Cardiol. 2012;59(23):2099-2100. doi:10.1016/j.jacc.2012.03.021 [http://content.onlinejacc.org/data/Journals/JAC/24307/03021.pdf PDF]</ref>

*74% of patients had a followup provocative study so this protocol should not be initiated if proper outpatient followup cannot be imitated<ref name="commentary"></ref>

*With a high combined sensitivity it offers promise for ruling out MACE but the low specificity may actually result in too stringent a criteria with unnecessary chest pain admissions.

==Funding==
Christchurch Cardio-Endocrine Research Group and the Queensland Emergency Medicine Research Foundation with (20%) contributions from industry (Abbott and Alere). Drs. Than, Cullen, and Parsonage, and Prof. Richards and Prof. Peacock had paid travel, accommodations, consulting fees, and honoraria from Abbott.

==Sources==
<references/>

[[Category:EBQ]][[Category:Cardiology]]

Pulmonary embolism

2014-05-07T11:34:14Z

Orinoco w: Additional considerations in imaging young female patients

==Background==
*Suspect in pt w/ dyspnea, tachypnea, or pleuritic pain
*Only 40% of ambulatory ED pts w/ PE have concomitant DVT

==Types==
#Massive
##Sustained hypotension (sys BP <90 for at least 15min or requiring inotropic support)
##Pulselessness
##Persistent profound bradycardia (HR <40 with signs of shock)
#Submassive
##Sys BP >90 but with either RV dysfunction or myocardial necrosis
###RV dysfunction
####RV dilation or dysfunction on TTE
####RV dilation on CT
####Elevation of BNP (>90)
####ECG: new complete or incomplete RBBB, anteroseptal ST elevation/depression or TWI<ref>David Da Costa. Bradycardias and atrioventricular conduction block BMJ. 2002 March 2; 324(7336): 535–538 </ref>
###Myocardial necrosis: Troponin I >0.4

==Diagnosis==
===Wells Criteria===
#Symptoms of DVT - 3pts
#No alternative diagnosis better explains the illness - 3pts
#HR > 100 - 1.5 pts
#Immobilization within prior 4wks - 1.5pts
#Prior history of DVT or PE - 1.5pts
#Active malignancy - 1pt
#Hemoptysis - 1pt

'''Wells Score'''
#0-1 point: Low probability (3.4%)
#2-6 points: Moderate probability (27.8%)
#7-12 points: High probability (78.4%)

===Workup by Probability===
====Low Probability====
*If low prob and [[PERC Rule]] neg then d/c
*If low prob and [[PERC Rule]] pos then d-dimer

====Moderate Probability====
*Obtain d-dimer

====High Probability====
*Consider anticoagulation before imaging!
*CTPA if GFR >60
*V/Q if GFR <60

* Also consider V/Q in young females in order to minimise radiation exposure to breast tissue
* Also consider V/Q vs CTPA in pregnant females depending on multiple considerations including the above + radiation burden to foetus

==Treatment==
===Anticoagulation===
*Indicated for all patients with confirmed PE or high clinical suspicion (don't wait for imaging)
*Treatment options:
**LMWH SC
***1st line for most hemodynamically stable pts
***contraindicated in renal failure
**UFH
***Consider in pts w/:
****Persistent hypotension
****Increased risk of bleeding
****Recent sx/trauma
****Renal failure (GFR <30)
****Morbid obesity or anasarca (poor sc absorption)
****Thrombolysis is being considered
***80 units/kg bolus; then 18 units/kg/hr
****Check PTT after 6hr; adjust infusion to maintain PTT at 1.5-2.5x control

===Thrombolysis===
====Indications====
#Pt w/ massive PE and acceptable risk of bleeding complications
#Pt w/ submassive PE w/ e/o adverse prognosis + low risk of bleeding complications
##Hemodynamic instability
##Worsening resp insufficiency
##Severe RV dysfunction
##Major myocardial necrosis

====Instructions====
#Review contraindications
#Discontinue heparin during infusion
#tPA 100mg over 2hr OR 0.6 mg/kg over 2min
#After infusion complete measure PTT
##Once value is <2x upper limit restart anticoagulation

====Absolute contraindications====
#Any prior intracranial hemorrhage,
#Known structural intracranial cerebrovascular disease (e.g. AVM)
#Known malignant intracranial neoplasm
#Ischemic stroke within 3mo
#Suspected aortic dissection
#Active bleeding or bleeding diathesis
#Recent surgery encroaching on the spinal canal or brain
#Recent closed-head or facial trauma w/ radiographic evidence of bony fx or brain injury

====Relative contraindications====
#Age >75 years
#Current use of anticoagulation
#Pregnancy
#Noncompressible vascular punctures
#Traumatic or prolonged CPR (>10min)
#Recent internal bleeding (within 2 to 4 weeks)
#History of chronic, severe, and poorly controlled hypertension
#Severe uncontrolled HTN on presentation (sys BP >180 or dia BP >110)
#Dementia
#Remote (>3 months) ischemic stroke
#Major surgery within 3 weeks

===IVC Filter===
*Indications
**anticoagulation contraindicated in pt with PE
**failure to attain adequate anticoagulation during treatment

==PE in Pregnancy==
*[[Heparin]] and [[Enoxaparin]] are safe (coumadin is not)
*Consider utz as initial test
*CT (with shield) vs. V/Q is roughly equilivalent radiation exposure
*D-Dimer MAY BE (no RCTs) used with following limits:
**1st trimester: <750 (+50% increase from normal lab threshold)
**2nd trimester: <1000 (+100% from normal)
**3rd trimester: <1250 (+150% from normal)

===Algorithm===
#Clinical features suggestive of PE
##Bilateral LE Ultrasound
###Positive-->LMWH
###Negative-->CTA

==External Links==
*[http://www.mdcalc.com/wells-criteria-for-pulmonary-embolism-pe/ MDCalc - Well's Criteria for Pulmonary Embolism]
*[http://www.mdcalc.com/perc-rule-for-pulmonary-embolism/ MDCalc - PERC Rule for Pulmonary Embolism]

==References==
<references/>
*Circulation. 2011 Apr 26;123(16):1788-830
*Tintinalli
*D-Dimer Concentrations in Normal Pregnancy: New Diagnostic Thresholds Are Needed. Kline et all. Clinical Chemistry May 2005 vol. 51 no. 5 825-829 http://www.clinchem.org/content/51/5/825.long

[[Category:Cards]]
[[Category:Pulm]]

User:Orinoco w

2014-05-07T11:29:56Z

Orinoco w: correct typo and add other university

Edward Tan, MBBS GCIPH.
University of Adelaide
University of Queensland