BMJ 2001;323:372 ( 18 August )

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Is it possible to exclude a diagnosis of myocardial damage within six hours of admission to an emergency department? Diagnostic cohort study

K R Herren, research fellow, ^a K Mackway-Jones, consultant, ^a C R Richards, research assistant, ^a C J Seneviratne, consultant clinical scientist, ^b M W France, consultant, ^b L Cotter, consultant. ^c

^a Department of Emergency Medicine, Manchester Royal Infirmary, Manchester M13 9WL, ^b Department of Clinical Biochemistry, Manchester Royal Infirmary, ^c Manchester Heart Centre, Manchester Royal Infirmary

Correspondence to: K Mackway-Jones kevin.mackway-jones{at}man.ac.uk

Objective: To assess the clinical efficacy and accuracy of an emergency department based six hour rule-out protocol for myocardial damage.
Design: Diagnostic cohort study.
Setting: Emergency department of an inner city university hospital.
Participants: 383 consecutive patients aged over 25 years with chest pain of less than 12 hours' duration who were at low to moderate risk of acute myocardial infarction.
Intervention: Serial measurements of creatine kinase MB mass and continuous ST segment monitoring for six hours with 12 leads.
Main outcome measure: Performance of the diagnostic test against a gold standard consisting of either a 48 hour measurement of troponin T concentration or screening for myocardial infarction according to the World Health Organization's criteria.
Results: Outcome of the gold standard test was available for 292 patients. On the diagnostic test for the protocol, 53 patients had positive results and 239 patients had negative results. There were 18 false positive results and one false negative result. Sensitivity was 97.2% (95% confidence interval 95.0% to 99.0%), specificity 93.0% (90.0% to 96.0%), the negative predictive value 99.6%, and the positive predictive value 66.0%. The positive likelihood ratio was 13.9 and the negative likelihood ratio 0.03.
Conclusions: The six hour rule-out protocol for myocardial infarction is accurate and efficacious. It can be used in patients presenting to emergency departments with chest pain indicating a low to moderate risk of myocardial infarction.

What is already known on this topic Many patients with chest pain in emergency departments indicating a low to moderate risk of myocardial infarction are admitted to rule out myocardial damage Some 6% of those discharged have undiagnosed myocardial damage What this study adds An emergency department based chest pain assessment unit protocol to rule out myocardial damage is sensitive enough to allow safe discharge of patients at low to moderate risk of myocardial infarction within six hours Such units can also reduce the number of patients admitted unnecessarily

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Rapid Responses:

Read all Rapid Responses

Measuring the wrong thing

Peter Viccellio
bmj.com, 19 Aug 2001 [Full text]

Accuracy depends on the gold standard

Y Sehgal
bmj.com, 20 Aug 2001 [Full text]

low incidence of MI

Y Sehgal
bmj.com, 20 Aug 2001 [Full text]

Re: Measuring the wrong thing

Katrina Herren
bmj.com, 22 Aug 2001 [Full text]

Re: Accuracy depends on the gold standard

Katrina Herren
bmj.com, 22 Aug 2001 [Full text]

Possibly a tool for identifying low risk patients

Carl E Palffy
bmj.com, 22 Aug 2001 [Full text]

Too quick rule out for acute MI -- Too dangerous

Rahul Gupta
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A randomised controlled trial and economic evaluation of a chest pain unit is in progress

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Swapping one admission headache for another

Matthew Reed
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