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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.
    • The EDACS-ADP safely identifies a higher proportion of patients as low-risk for MACE than other ACS clinical decision scores.
    • Like other chest pain evaluation studies, the primary outcome was MACE (major adverse cardiac event), as defined by any of the following:
      • ST-elevation or non-ST-elevation MI.
      • Need for emergency revascularization.
      • Death from cardiovascular causes.
      • Ventricular arrhythmia.
      • Cardiac arrest.
      • Cardiogenic shock.
      • High atrio-ventricular block.
    • The goal of these rules is to identify a low-risk population that needs less testing than 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 original study (see Evidence Appraisal).
    • 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 0-hr and 2-hr 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 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 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 0-hr and 2-hr 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 0-hr 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 second troponin is positive, this patient no longer qualifies as low-risk.

    Facts & Figures

    Low risk cohort:

    • EDACS <16 and
    • EKG shows no new ischemia and
    • 0-hr and 2-hr troponin both negative.

    Recommendation for low risk cohort: 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 or
    • 0-hr or 2-hr troponin positive.

    Recommendation for not low risk cohort: proceed with usual care with further observation and delayed troponin.

    Evidence Appraisal

    In the original paper, the EDACS-ADP was 99-100% sensitive 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, Marburg, and GRACE.

    In the original EDACS-ADP cohorts, the prevalence of MACE in the study overall was 13-15%.

    A 2016 prospective, pragmatic randomized controlled trial of 558 patients in New Zealand (Than 2016) comparing the EDACS-ADP and ADAPT-ADP found that the EDACS identified a higher proportion of low-risk patients (41.6% vs. 30.5%) with both groups having a NPV of 100%. However, the primary outcome of the proportion of patients safely discharged within 6 hours was the same in EDACS and ADAPT-ADP groups (32.3% vs. 34.4% respectively).

    A 2016 retrospective external validation (Flaws 2016) of 763 patients in Vancouver, Canada found the EDACS-ADP to have 100% sensitivity and 100% negative predictive value, while correctly identifying 41.6% of its cohort as low risk.

    A very large 2018 retrospective study of 118,822 patients treated in the Kaiser system in Northern California from 2013-2015 (Mark 2018), compared the modified HEART score to the original and simplified EDACS rules and found that while all scores predicted low risk 60-day MACE (NPVs of >99% in all cases), the original EDACS identified a larger proportion of low risk patients (60.8%) vs. the HEART score (51.8%) or simplified EDACS (48.1%).

    Literature

    Validation

    Research PaperThan MP, Pickering JW, Aldous SJ, Cullen L, Frampton CM, Peacock WF, Jaffe AS, Goodacre SW, Richards AM, Ardagh MW, Deely JM, Florkowski CM, George P, Hamilton GJ, Jardine DL, Troughton RW, van Wyk P, Young JM, Bannister L, Lord SJ. Effectiveness of EDACS Versus ADAPT Accelerated Diagnostic Pathways for Chest Pain: A Pragmatic Randomized Controlled Trial Embedded Within Practice. Ann Emerg Med. 2016 Jul;68(1):93-102Research PaperFlaws D, Than M, Scheuermeyer FX, Christenson J, Boychuk B, Greenslade JH, Aldous S, Hammett CJ, Parsonage WA, Deely JM, Pickering JW, Cullen L. External validation of the emergency department assessment of chest pain score accelerated diagnostic pathway (EDACS-ADP). Emerg Med J. 2016 Sep;33(9):618-25Research PaperMark DG, Huang J, Chettipally U, Kene MV, Anderson ML, Hess EP, Ballard DW, Vinson DR, Reed ME; Kaiser Permanente CREST Network Investigators. Performance of Coronary Risk Scores Among Patients With Chest Pain in the Emergency Department. J Am Coll Cardiol. 2018 Feb 13;71(6):606-616
    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

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