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    ADAPT Protocol for Cardiac Event Risk

    Assesses chest pain patients at 2 hours for risk of cardiac event.
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    When to Use
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    Why Use

    The ADAPT Score and Accelerated Diagnostic Protocol can be used to evaluate patients with chest pain and potentially identify 20% of patients who are low-risk and can be evaluated with a 0-hour and 2-hour troponin test along with EKG and TIMI Risk Scores (for STEMI and UA/NSTEMI).

    • Included patients ≥18 years of age with at least 5 minutes of symptoms that could be possible ACS.
    • Patients perceived to be “high risk” were not excluded unless EKG showed STEMI.
    • If patient was unsure about a diagnosis (like “history of hypertension,”) this was assumed to be “No.”
    • EKG changes were defined as ST-segment depression of at least 0.05 mV in ≥2 contiguous leads (including reciprocal changes), T-wave inversion of at least 0.1 mV, or Q waves ≥30 ms in width and ≥0.1 mV in depth in at least 2 contiguous leads.
    • Three quarters of patients in the low-risk group still got follow-up testing within 30 days (most got a stress test).

    Up to 20% of chest pain patients may be able to be safely ruled out for MI and ACS within 2 hours of arrival in the ED, reducing length of stay dramatically without adverse outcome.

    TIMI Risk Score for UA/NSTEMI
    Note: The TIMI Risk Score for UA/NSTEMI includes cardiac enzymes and ST deviation which are listed above and therefore excluded from the TIMI inputs below.

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    Barring other concerning features for acute coronary syndrome or other life-threatening causes of chest pain (pneumothorax, pulmonary embolism, cardiac tamponade, aortic dissection, esophageal rupture, etc.), patients that meet the low-risk criteria can be considered for discharge with close follow-up with their primary care physician after negative 0h and 2h troponin testing.

    Patients who do not meet the low-risk criteria should be ruled-out for myocardial infarction with serial EKGs and biomarkers and risk stratified as per normal chest pain guidelines and protocols.

    Management

    • For low-risk patients: consider other causes of chest pain due to aortic, esophageal, pulmonary, cardiac, and abdominal, and musculoskeletal sources prior to discharge.
    • For non-low-risk patients: Treat as per usual chest pain protocols, including but not limited to consideration of aspirin, nitroglycerin, and serial EKGs and biomarkers at minimum.

    Formula

    Addition of the selected points:

     

    0 points

    1 point

    Abnormal troponin*

    No

    Yes

    Abnormal EKG**

    No

    Yes

    TIMI Risk Score for UA/NSTEMI

    0

    >0


    *cTnI level at 0 and 2 hours above institutional cutoff for elevated troponin.

    **ST-segment depression of at least 0.05 mV in ≥2 contiguous leads (including reciprocal changes), T-wave inversion of at least 0.1 mV, or Q waves ≥30 ms in width and ≥0.1 mV in depth in at least 2 contiguous leads.

    Facts & Figures

     

     

    Risk group

    Risk of major adverse cardiac event (MACE) in 30 days

    Normal troponin, normal EKG and TIMI 0

    Low

    0-0.3%*

    Normal troponin, normal EKG and TIMI 1

    Intermediate

    0.8%**

    Abnormal troponin or abnormal EKG and any TIMI

    High

    15.3%***


    *Per
    Than 2012.

    **Per Cullen 2013. The study examined patients with TIMI 0 or 1, with no reported data for patients with TIMI >1 (presuming according to TIMI data, risk of MACE increases with increasing TIMI Score).

    ***Per Than 2012. In the original paper, 15.3% of patients studied (302 of 1,975 total) had a MACE, and only 1 patient was identified as low risk.

    Evidence Appraisal

    • The ADAPT accelerated diagnostic protocol (ADP) was 99.7% sensitive for identifying a low-risk population of chest pain patients.
    • 15.3% of patients overall in the study had the primary outcome event of “major adverse cardiac event” (MACE) which includes MI, emergency revascularization, death, ventricular arrhythmia, cardiac arrest, cardiogenic shock, or high-degree AV block.
    • The ADAPT accelerated diagnostic protocol was able to identify 20% of the entire cohort of 1,975 patients as “low risk.”
    • One patient was classified as low risk who then had an elevated troponin at 12 hours, had stenting of the right coronary and circumflex arteries, and had “no further cardiac problems during 1 year of follow-up.”
    • If a TIMI Score of 1 was used instead of 0, the false-negative rate was 3%.

    Literature

    Dr. Martin Than

    About the Creator

    Martin Than, MD, is an emergency medicine specialist at Christchurch Public Hospital. He is the co-director and co-founder of the Clinical Decision Support Unit and is involved in creating a National Trauma Audit Database and reviewing emergency air ambulance and helicopter services. He has trained and worked in Emergency Medicine in the UK, Canada, Australia and New Zealand.

    To view Dr. Martin Than's publications, visit PubMed