Objective To validate a triage flowchart to rule out acute coronary syndrome (ACS) in chest pain patients attending the emergency department (ED).
Methods An observational cohort study of consecutive patients. In all cases, a previously derived five-step triage flowchart (age ≤40 years, absence of diabetes, not previously known coronary artery disease, non-oppressive and non-retrosternal pain) was applied. Patients meeting all five discriminators were grouped as ‘five-step triage non-ACS’, the rest as ‘five-step triage ACS’. The same strategy was used with a four-step model (without age ≤40 years). After ED study and 1-month follow-up, patients were definitively classified as ‘true ACS’ or ‘true non-ACS’. Validity indexes and receiver operating characteristics curves were calculated.
Results 4231 patients were included: 918 (21.7%) were ‘true ACS’, 3303 (78.1%) ‘true non-ACS’; 10 (0.2%) were lost to follow-up. The five-step triage flowchart classified 4000 (94.8%) as ‘triage ACS’ and 221 (5.2%) as ‘triage non-ACS’; none of the latter was ‘true ACS’. The four-step model classified 3194 (75.6%) as ‘triage ACS’ and 1027 (24.4%) as ‘triage non-ACS’. A ‘true ACS’ was seen in 26 patients from the latter group. Accordingly, five-step triage flowchart specificity and positive predictive value (PPV) to rule out ACS were 100% (95% CI 100% to 100%). For the four-step model specificity and PPV were 97% (95% CI 96% to 98%).
Conclusion The five-step triage flowchart identifies chest pain patients without an ACS. However, only 5% of these patients meet these five criteria. A simpler model allows greater patient inclusion but a higher risk of misclassification of true ACS.
- Acute coronary syndrome
- cardiac care
- chest pain
- chest pain unit
- emergency care systems
- emergency department
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Funding OM received grant support from the Instituto de Salud Carlos III in 2009.
Competing interests None.
Patient consent Obtained.
Ethics approval This study was conducted with the approval of the hospital's institutional review broad.
Provenance and peer review Not commissioned; externally peer reviewed.