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Emergency Department Triage Strategies for Acute Chest Pain Using Creatine Kinase–MB and Troponin I Assays: A Cost-Effectiveness Analysis

Carísi A. Polanczyk, MD, MSc; Karen M. Kuntz, ScD; David B. Sacks, MB, ChB; Paula A. Johnson, MD, MPH; and Thomas H. Lee, MD, ScD
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From Brigham and Women's Hospital, Harvard Medical School, and Harvard School of Public Health, Boston, Massachusetts.

Grant Support: Dr. Polanczyk is sponsored by a scholarship from CAPES, Brasilia, Brazil.

Requests for Reprints: Thomas H. Lee, MD, Partners Community HealthCare, Inc., Suite 1150, Prudential Tower, Boston, MA 02119; e-mail, thlee@partners.org. For reprint orders in quantities exceeding 100, please contact the Reprints Coordinator; phone, 215-351-2657; e-mail, reprints@mail.acponline.org.

Current Author Addresses: Dr. Polanczyk: Hospital de Clinicas de Porto Allegre, Rua Ramiro Barcelos 2350/2228, Porto Allegre, Brazil 90000.

Dr. Kuntz: Harvard School of Public Health, 718 Huntington Avenue, Boston, MA 02115.

Drs. Sacks and Johnson: Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.

Dr. Lee: Partners Community HealthCare, Inc., Prudential Tower, Suite 1150, 800 Boylston Street, Boston, MA 02199-8001.

Ann Intern Med. 1999;131(12):909-918. doi:10.7326/0003-4819-131-12-199912210-00002
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Several tests can assist clinicians in the evaluation of patients with acute chest pain, the most readily available of which are biochemical markers of myocardial damage and exercise testing. These tests are generally considered unnecessary in patients at very low risk for myocardial infarction, for whom immediate discharge from the emergency department is appropriate. However, they are commonly used in patients who are admitted to the hospital or held for several hours of observation because of suspected myocardial ischemia.

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Figure 1.
Decision model used to assess the cost-effectiveness of triage strategies in patients presenting to the emergency department with acute chest pain.CKECG+MIUA

Five different strategies using creatine kinase ( )-MB and troponin I are compared with benchmark extreme strategies of hospitalizing all patients or not performing any test. Patients with abnormal results on tests for cardiac markers are hospitalized, and patients with negative test results are discharged. For example, in the fourth strategy, patients undergo CK-MB mass testing. If the results are positive, patients are hospitalized; if they are negative, patients are tested for troponin I only if there is evidence of new ischemic changes on the electrocardiogram ( ). If troponin I values are abnormal, patients are hospitalized. In this model, patients with normal cardiac marker values undergo exercise treadmill testing; if results are negative, the patients are discharged home. Patients are classified as having myocardial infarction ( ), unstable angina ( ), or other disease states (“Other”), for which the models estimate a life expectancy. Squares denote decision events and circles denote chance events.

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Figure 2.
Two-way sensitivity analysis from the model with exercise treadmill testing.

Incremental cost-effectiveness ratio of exercise testing relative to measurement of creatine kinase–MB mass alone is given for each age group for different probabilities of myocardial infarction. The percentages in the middle of the graph are the prior probability of unstable angina.

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Summary for Patients

Strategies for the Emergency Room Evaluation of Patients with Chest Pain

The summary below is from the full report titled “Emergency Department Triage Strategies for Acute Chest Pain Using Creatine Kinase-MB and Troponin I Assays: A Cost-Effectiveness Analysis.” It is in the 12 December 1999 issue of Annals of Internal Medicine (volume 131, pages 909-919). The authors are C.A. Polanczyk, K.M. Kuntz, D.B. Sacks, P.A. Johnson, and T.H. Lee.


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