ADAPT Protocol for Cardiac Event Risk

Why Use

Up to 20% of chest pain patients may be able to be safely ruled out for MI and ACS within 2 hours of arrival in the ED, reducing length of stay dramatically without adverse outcome.

When to Use

The ADAPT Score and Accelerated Diagnostic Protocol can be used to evaluate patients with chest pain and potentially identify 20% of patients who are low-risk and can be evaluated with a 0-hour and 2-hour troponin test along with EKG and TIMI Risk Scores (for STEMI and UA/NSTEMI ).

Formula

Pearls / Pitfalls

Included patients ≥18 years of age with at least 5 minutes of symptoms that could be possible ACS. Patients perceived to be “high risk” were not excluded unless EKG showed ST-Elevation Myocardial Infarction (STEMI). If patient was unsure about a diagnosis (like “history of hypertension,”) this was assumed to be “No.” EKG changes were defined as ST-segment depression of at least 0.05 mV in ≥2 contiguous leads (including reciprocal changes), T-wave inversion of at least 0.1 mV, or Q waves ≥30 ms in width and ≥0.1 mV in depth in at least 2 contiguous leads. 3/4 of patients in the low-risk group still received follow-up testing within 30 days (most with an outpatient stress test).

Management

For low-risk patients: consider other causes of chest pain due to aortic, esophageal, pulmonary, cardiac, and abdominal, and musculoskeletal 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.

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.

More Information

Risk group Risk of major adverse cardiac event (MACE) in 30 days Normal troponin, normal EKG and TIMI 0 Low 0-0.3%* Normal troponin, normal EKG and TIMI 1 Intermediate 0.8%** Abnormal troponin or abnormal EKG and any TIMI High 15.3%*** *Per Than 2012 . **Per Cullen 2013 . The study examined patients with TIMI 0 or 1, with no reported data for patients with TIMI >1 (presuming according to TIMI data, risk of MACE increases with increasing TIMI Score). ***Per Than 2012 . In the original paper, 15.3% of patients studied (302 of 1,975 total) had a MACE, and only 1 patient was identified as low risk.