Department of Emergency Medicine, National Taiwan University,Taipei 106,TaiwanTaiwan
Department of Medicine, College of Medicine, National Taiwan University,Taipei,TaiwanTaiwan
Also available as PDF (figures and tables appear in the PDF).
Cardiovascular disease is a leading cause of mortality and morbidity worldwide. In 2013, an estimated 8.14 million people died from acute myocardial infarction (AMI) globally. Emergency department (ED) is the main portal of entry for patients with acute chest pain symptoms. Approximately 10% of all emergency department (ED) patients presented with chest pain complaint. However, only 13-23.6% of these patients are finally diagnosed with AMI.
Open Journal PUBLISHERS Editorial A Decision Support System is Needed for Rapid Triage of Chest Pain Patients Using High Sensitivity Troponin Testing-Based Algorithms 1* 1 2 2 Chien-Chang Lee, MD, ScD ; Cheng-Heng Liu, MD ; Sih-Shiang Huang, MD ; Cho-Han Chiang 1Department of Emergency Medicine, National Taiwan University,Taipei 106,Taiwan 2Department of Medicine, College of Medicine, National Taiwan University,Taipei,Taiwan * *Corresponding author Chien-Chang Lee, MD, ScD Director, Department of Emergency Medicine, National Taiwan University Hospital, No. 7, Chung-Shan South Road,Taipei 100,Taiwan; Tel. +886-2-23123456 ext 62831; Article information st th nd Received: March 21 , 2019; Accepted: March 25 , 2019; Published: April 2 , 2019 Cite this article Lee C-C, Liu C-H, Huang S-S, Chiang C-H.A decision support system is needed for rapid triage of chest pain patients using high sensitivity troponin testing-based algorithms. Emerg Med Open J. 2019; 5(1): e1-e2. doi: 10.17140/EMOJ-5-e006 ardiovascular disease is a leading cause of mortality and mor- nosis algorithms, such as 0-, 1-, or 2-hour algorithm, have been bidity worldwide. In 2013, an estimated 8.14 million people developed and implemented based on the high sensitivity nature C 1 8-10 died from acute myocardial infarction (AMI) globally. Emergen- of new generation troponins. One such promising algorithm is cy department (ED) is the main portal of entry for patients with the 0/1-hour algorithm recommended by the European Society of acute chest pain symptoms. Approximately 10% of all emergency Cardiology (ESC).11 This algorithm combines assay-specific cutoff department (ED) patients presented with chest pain complaint.2 values of hs-cTn at presentation and the absolute 1-hour changes However, only 13-23.6% of these patients are finally diagnosed (0-1 delta) to rapidly rule out or rule in patients with NSTEMI. with AMI.3 Patients with segment (ST) elevation MI (STEMI) Thus, clinical decision could be made for patients who presented could be rapidly recognized by electrocardiogram (ECG) exam, to the ED with suspected AMI or ACS in just 2 to 3 hours after but patients with non-ST elevation MI (NSTEMI) could not be ED presentation. Although concern has been raised regarding the efficiently excluded or included by contemporary cardiac troponin safety of the 0/1-hour algorithm in patients with renal dysfunc- assays. Contemporary troponin assay could not detect the presence tion, in a recent work, Twerenbold R showed the 0/1-hour algo- of cardiac troponins in the peripheral circulation until 6 to 8 hours rithms using either high-sensitivity cardiac troponin T or troponin after the onset of MI.4 Therefore, patients presenting to the ED I can rule out MI rapidly and safely.12 In addition, recent studies with chest pain usually require serial troponin measurements over have shown combining HEART score or combining hs-cTnT and 6 to 8 hours before the possibility of MI can be safely excluded. hs-cTnI may further enhance the accuracy of the rapid diagnosis 13,14 Failure in early detection results in higher rate of complications algorithm.
and mortality. The delay in ruling out MI constitutes a major cause of ED crowding, and the delay in ruling in MI may lead to poor Despite the rapid development of various high sensitivity prognosis. It has been shown early evidence-based management, troponin testing based accelerated diagnosis system, the implemen- including antiplatelet treatment and revascularization, may decrease tation of the newly developed algorithms in ED have been slow. mortality, shorten hospitalization, and improve overall outcome.5 One of the big obstacle is the complexity of the algorithms that include several cutoff values of troponin at several time points. The introduction of high sensitive cardiac troponin (hs- The addition of scoring systems and multiple markers strategy fur- cTn) assays in 2010 has shown promise to enhance the accuracy and ther complicates the decision process. Because the hospital central efficiency of MI diagnosis in the ED tremendously.6 These assays laboratory conventionally reports only the test results with refer- measure cTn in the single digit range of nanograms per liter, about ence value, an emergency physician therefore, has to memorize the 10- to 100-fold lower than the contemporary cTn assays.7 This has complex algorithms. The 1-hour algorithm is a very good example led to the development of several hs-cTn-based accelerated diag- that a clinical decision support system will help clinicians make nostic algorithms to triage patients with suspected acute coronary evidence-supported decisions. A decision support system will help syndromes (ACS) efficiently and safely.6 Several accelerated diag- remind the various time points for blood sampling and also pro- cc Copyright 2019 by Lee C-C. This is an open-access article distributed under Creative Commons Attribution 4.0 International License (CC BY 4.0), which allows Emerg Med Open J. 2019; 5(1): e1-e2. doi: 10.17140/EMOJ-5-e006 vide reference cutoff values of troponin tests at different time ac troponin. Intern Emerg Med. 2017; 12(2): 147-155. doi: 10.1007/ points.15 In addition, the system can also remind the physician with s11739-017-1612-1 the update prognosis data in different decision groups and auto- matically calculates TIMI, GRACE or HEART scores. Up to date, 8. Body R, Carley SD, McDowell G, et al. Use of low level high such system is not commercially available, but the design and im- sensitivity troponin to rule out acute myocardial infarction in the plementation of such system in the laboratory information system emergency department. European Heart Journal. Supplement 2010; is not technically difficult. We call for the design of such a system 12: F111-F112.
to help emergency physicians make evidence-based decision in the era of information tsunami.
9. Reichlin T, Schindler C, Drexler B, et al. One-hour rule-out and rule-in of acute myocardial infarction using high-sensitivity car- CONFLICTS OF INTEREST diac troponin T. Arch Intern Med. 2012; 172(16): 1211-1218. doi: 10.1001/archinternmed.2012.3698 The authors declare that they have no conflicts of interest. 10. Reichlin T, Cullen L, Parsonage WA, et al. Two-hour algorithm