Clinical decision rules to enable exclusion of acute coronary syndromes in Emergency Department patients with chest pain

BACKGROUND Diagnosis of acute coronary syndromes (ACS) in the Emergency Department (ED) is a topical and contentious issue. Current diagnostic techniques rely on hospital admission for troponin testing. Only a minority of those admitted prove to have ACS while unacceptable proportions of those discharged have unrecognised ACS. AIMS We aimed to evaluate the diagnostic and prognostic value of individual clinical findings and novel biomarkers in ED patients with suspected cardiac chest pain. We then aimed to derive a clinical decision rule (CDR) to potentially enable safe, immediate discharge of a proportion of patients from the ED while risk stratifying others to facilitate triage to an appropriate level of in-patient care. METHODS We recruited patients who presented to the ED with suspected cardiac chest pain. Variables that have previously been shown to predict diagnosis of acute myocardial infarction (AMI) or to predict outcome were prospectively recorded. Blood was drawn at presentation for levels of eight biomarkers. Patients underwent 12-hour troponin testing and were followed up for the composite primary outcome of AMI, death or urgent coronary revascularisation for six months. Variables that were univariate predictors (p