Point-of-Care Testing for Conventional Cardiac Markers:

The feasibility and diagnostic accuracy by multiple cardiac biomarkers in emergency chest pain patients: a clinical analysis to compare 290 suspected acute coronary syndrome cases stratified by age and gender in Taiwan

Background

Accurate diagnosis of acute coronary syndrome (ACS) in a timely fashion is challenging in the elderly population, especially elderly women, who usually exhibit atypical clinical symptoms. A multiple cardiac biomarker (MCB) based approach has been shown to improve diagnostic efficacy of ACS. However, data in various age groups and sex differences remain largely unexplored.

Methods

Point-of-care testing (POCT) was performed on 290 patients (aged ≥18 years) who were admitted to the emergency department (ED) with symptoms of acute chest pain under suspicion of acute coronary syndrome (ACS). The MCB approach in current work assessed four cardiac biomarkers: myoglobin, troponin I, creatine kinase-myocardial band isoenzyme fraction (CK-MB), and brain natriuretic peptide (BNP).

Results

Overall, the MCB approach demonstrated considerably higher sensitivity for elderly patients than for younger patients in identifying ACS (80.0 % [64.1–90.0] vs. 52.6 % [37.3–67.5] for ≥65 years and <65 years groups), with younger population showed greater specificity (44.1 % [35.3–53.4] vs. 84.9 % [76.9–90.5] for ≥65 years and <65 years groups, respectively). The highest sensitivity achieved for elderly women who reported chest pain was 87.5 % [95 % CI: 64–96.5]). In general, the sensitivity of this approach was higher for female patients than for male patients (80 % [58.4–91.9] vs. 61 % [47.8–73.0]).

Conclusions

The MCB approach can provide a quick and accurate clinical diagnosis in elderly and female patients, both of whom have traditionally proven to be challenging to diagnose from suspected acute coronary syndrome.

Implementation of a rapid chest pain protocol in the emergency department: A quality improvement project

PURPOSE

The purpose of this quality improvement (QI) project is to compare the effectiveness of a rapid 90-min chest pain screening and evaluation protocol to a 120-min screening and evaluation protocol in determining patient readiness for hospital admission or discharge home.

DATA SOURCES

The existing chest pain protocol utilized in the emergency department (ED) was revised based on a review of current research changing initial screening and reevaluation times from 120 to 90 min. A prospective comparative study of patients presenting to the ED with chest pain was performed comparing the existing chest pain protocol of 120 min (standard care) with a rapid screening evaluation protocol of 90 min. A total of 128 patients presenting to an ED in Texas with chest pain comprised the sample for this study.

CONCLUSIONS

There was a significant difference in the number of minutes between the groups for readiness for disposition. The average time from chest pain evaluation to readiness for disposition home, observation, or admission decreased from an average of 191 min in the standard care group to an average of 118 min in the rapid screening group.

IMPLICATIONS FOR PRACTICE

Use of the rapid screening and evaluation protocol decreased the time to disposition by an average of 73 min, which enhanced ED flow without influencing disposition and patient safety.

Use of saliva-based nano-biochip tests for acute myocardial infarction at the point of care: a feasibility study

BACKGROUND

For adults with chest pain, the electrocardiogram (ECG) and measures of serum biomarkers are used to screen and diagnose myocardial necrosis. These measurements require time that can delay therapy and affect prognosis. Our objective was to investigate the feasibility and utility of saliva as an alternative diagnostic fluid for identifying biomarkers of acute myocardial infarction (AMI).

METHODS

We used Luminex and lab-on-a-chip methods to assay 21 proteins in serum and unstimulated whole saliva procured from 41 AMI patients within 48 h of chest pain onset and from 43 apparently healthy controls. Data were analyzed by use of logistic regression and area under curve (AUC) for ROC analysis to evaluate the diagnostic utility of each biomarker, or combinations of biomarkers, in screening for AMI.

RESULTS

Both established and novel cardiac biomarkers demonstrated significant differences in concentrations between patients with AMI and controls without AMI. The saliva-based biomarker panel of C-reactive protein, myoglobin, and myeloperoxidase exhibited significant diagnostic capability (AUC = 0.85, P < 0.0001) and in conjunction with ECG yielded strong screening capacity for AMI (AUC = 0.96) comparable to that of the panel (brain natriuretic peptide, troponin-I, creatine kinase-MB, myoglobin; AUC = 0.98) and far exceeded the screening capacity of ECG alone (AUC approximately 0.6). En route to translating these findings to clinical practice, we adapted these unstimulated whole saliva tests to a novel lab-on-a-chip platform for proof-of-principle screens for AMI.

CONCLUSIONS

Complementary to ECG, saliva-based tests within lab-on-a-chip systems may provide a convenient and rapid screening method for cardiac events in prehospital stages for AMI patients.

Impact of point-of-care testing in the emergency department evaluation and treatment of patients with suspected acute coronary syndromes

OBJECTIVES

To assess the impact of point-of-care testing (POCT) for troponin I (cTnI) measurement on the time to anti-ischemic therapy (TAIT) for patients with suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) presenting to the emergency department (ED).

METHODS

This was an open-label, randomized, single-center trial conducted in a university-affiliated hospital. cTnI measurement of patients with suspicion of NSTE-ACS coming to the ED was randomly allocated to POCT or central hospital laboratory testing (CHLT). The authors compared patients' baseline characteristics, time to anti-ischemic therapy, and medical outcomes between the randomized groups, in all study participants and in high-risk NSTE-ACS (cTnI level >or= 0.10 microg/mL), and in those with low suspicion ACS (no chest pain and no ST deviation).

RESULTS

Of the 860 patients enrolled, 113 were high-risk NSTE-ACS patients, including 53 (46.9%) allocated to POCT and 60 (53.1%) to CHLT. POCT was associated with decreased time to anti-ischemic therapy of about three-quarters of an hour, which was due to a shorter time to physician notification of cTnI level, in both all and subgroup participants. In contrast, neither ED length of stay nor medical outcomes differed between study groups.

CONCLUSIONS

Point-of-care testing for cTnI measurement might be clinically relevant for ED patients with a suspicion of NSTE-ACS, particularly for high-risk patients with a low suspicion of ACS.

The value of bedside cardiac multibiomarker assay in rapid and accurate diagnosis of acute coronary syndromes

For emergency department physicians, timely triage and risk stratification of chest pain patients remains a challenge. Faced with an aging population and the growing prevalence of heart disease, clinicians are seeking more effective ways to diagnose acute coronary syndromes rapidly and accurately. Emergency department physicians must make critical and time-sensitive decisions based on patient history, physical examination, and 12-lead electrocardiogram as justification for diagnosis of acute coronary syndromes. But because most of these tools are not reliable independently, these incomplete strategies can result in costly and inappropriate treatment decisions.