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    Emergency Department Assessment of Chest Pain Score (EDACS)

    Identifies chest pain patients with low risk of major adverse cardiac event.
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    Patients with chest pain or other anginal symptoms requiring evaluation for possible acute coronary syndrome who may be potentially low risk and appropriate for early discharge from the emergency department.

    • The EDACS-ADP study included any symptoms >5 minutes that the attending thought were worth working up for possible ACS.
      • This is a broader definition than other studies like the Vancouver Chest Pain Score which only included chest pain patients specifically.
    • Like other chest pain evaluation studies, the primary outcome was MACE (major adverse cardiac event), as defined by:
      • ST-elevation or non-ST- elevation MI
      • Required an emergency revascularisation procedure
      • Had died of cardiovascular causes,
      • Had suffered a ventricular arrhythmia,
      • Cardiac arrest
      • Cardiogenic shock or
      • High atrio-ventricular block
    • The goal of these rules is to identify a low-risk population that needs less testing than other higher-risk patients (it is a rule-out rule to “rule-out” patients at high risk of cardiac disease, and therefore is not terribly specific).
    • Goals for sensitivity of the rule were ≥99% and this was achieved in the study (see Evidence-Based Medicine).
    • The score was created initially without EKG or biomarkers, so that these could then be included in the EDACS-ADP (accelerated diagnostic protocol), which does include EKG and troponin testing at 0h and 2 hours.

    Patients requiring serial blood testing (serial troponin markers typically at 0 and 6-hours to rule out myocardial infarction) and further risk stratification require an extended emergency department evaluation, leading to crowding and bed allocation problems. The authors of this study were able to find a low-risk group of patients (~45%) that could safely be discharged from the ED after two biomarkers, EKG, and history and physical exam.

    This score only applies to patients: (1) ≥18 years old with normal vital signs; (2) Chest pain consistent with ACS; (3) No ongoing chest pain or crescendo angina
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    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 muskuloskeletal 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.

    Critical Actions

    Low Risk: Patient safe for discharge to early outpatient follow-up investigation (or proceed to earlier inpatient testing).

    Not Low Risk: Proceed with usual care with further observation and delayed troponin.

    Formula

    Addition of the selected points; points assigned below. If score is <16, patient can be evaluated in the “low risk” group with non-ischemic EKG and negative 0h and 2h troponins. These patients with these two additional features are low-risk for major adverse cardiac event.

    If score is ≥16 or EKG shows new ischemia or 0h troponin is negative, then the patient is not low-risk and not appropriate for early discharge. (Obviously if the first troponin is negative and the patient is in the low-risk group, but the 2nd troponin is positive, this patient no longer qualifies as low-risk.

    Facts & Figures

    Low Risk Cohort:

    • EDACS < 16 and
    • If EKG shows no new ischemia and
    • 0h and 2h troponin both negative
    • Recommendation: safe for discharge to early outpatient follow-up investigation (or proceed to earlier inpatient testing).

     

    Not Low Risk Cohort:

    • EDACS ≥16 or
    • EKG shows new ischemia
    • 0h or 2h troponin positive
    • Recommendation: Proceed with usual care with further observation and delayed troponin.

    Evidence Appraisal

    • The EDACS-ADP was propsectively validated in the original paper but would be strengthened by an external validation as well.
    • The EDACS-ADP was 99-100% senstive for correctly identifying patients as low-risk and identified 45% of its cohort as low-risk. This is much higher than other ED-based risk scores like HEART, Vancouver Chest Pain Score, ADAPT, Marberg, and GRACE.
    • In the EDACS-ADP cohorts, the prevalence of MACE the study overall was 13-15%.
    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