Ischaemic heart disease

Chest pain assessment changes promote early discharge in COVID-19 pandemic

‘Accelerated discharge’ adaptations to ACS assessment pathways aim to reclassify patients as low risk to reduce demand on hospital services in the COVID-19 pandemic environment.

A CSANZ position statement released on 24 April advises that evaluation of patients presenting with chest pain can be safely modified to rapidly re-stratify a substantial proportion of ‘intermediate risk’ patients as ‘low risk’ to facilitate earlier discharge from hospital.

They recommend early identification of low risk patients who do not require further testing for ischaemia, either by using a single test of troponin on presentation or clinical risk stratification and serial testing of ECG and troponin only.

The CSANZ statement also recommends identification of low risk patients who can safely be discharged from ED with expedited outpatient review and consideration of further testing.

The criteria that identify high risk patients remain unchanged.

According to the CSANZ, between 5-20% of patients presenting with chest pain prove to be due to acute coronary syndrome.  But the large number of patients presenting with no high risk features “pose a diagnostic challenge and consume significant health resources,” they note.

And with possible restrictions on hospital resources during the COVID-19 pandemic, “modification of existing processes may be required to accommodate unprecedented demand on health services.”

They says several studies and large meta-analyses have shown that in patients without high-risk features a single test of cardiac troponin using a highly sensitive troponin assay can identify patients at a very low risk of death AMI, or other major adverse cardiac events, at 30 days with very high sensitivity and negative predictive value.

“The evidence supporting these adaptations to existing guidelines indicates that in patients discharged from hospital the sensitivity to exclude AMI during admission is >98% with a negative predictive >99% with similar parameters for the risk of ACS at 30 days of follow up.

The position statement includes a new algorithm which advises accelerated discharge for patients who meet the following criteria:

  • ECG – no ischaemic change;
  • First hsTn on or below cut off;
  • Symptom onset  two or more 2 hours prior to troponin test;
  • Age over 18 years.

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