Is it possible to exclude a diagnosis of myocardial damage within six hours of admission to an emergency department? Diagnostic cohort study

Abstract

Objective: To assess the clinical efficacy and accuracy of an emergency department based six hour rule-out protocol for myocardial damage. Design: Diagnostic cohort study. Setting: Emergency department of an inner city university hospital. Participants: 383 consecutive patients aged over 25 years with chest pain of less than 12 hours' duration who were at low to moderate risk of acute myocardial infarction. Intervention: Serial measurements of creatine kinase MB mass and continuous ST segment monitoring for six hours with 12 leads. Main outcome measure: Performance of the diagnostic test against a gold standard consisting of either a 48 hour measurement of troponin T concentration or screening for myocardial infarction according to the World Health Organization's criteria. Results: Outcome of the gold standard test was available for 292 patients. On the diagnostic test for the protocol, 53 patients had positive results and 239 patients had negative results. There were 18 false positive results and one false negative result. Sensitivity was 97.2% (95% confidence interval 95.0% to 99.0%), specificity 93.0% (90.0% to 96.0%), the negative predictive value 99.6%, and the positive predictive value 66.0%. The positive likelihood ratio was 13.9 and the negative likelihood ratio 0.03. Conclusions: The six hour rule-out protocol for myocardial infarction is accurate and efficacious. It can be used in patients presenting to emergency departments with chest pain indicating a low to moderate risk of myocardial infarction. Many patients with chest pain in emergency departments indicating a low to moderate risk of myocardial infarction are admitted to rule out myocardial damage Some 6% of those discharged have undiagnosed myocardial damage An emergency department based chest pain assessment unit protocol to rule out myocardial damage is sensitive enough to allow safe discharge of patients at low to moderate risk of myocardial infarction within six hours Such units can also reduce the number of patients admitted unnecessarily. © 2001, BMJ Publishing Group Ltd. All rights reserved.