Trainee-led study spurs change in chest pain care

Photograph of Cara Barnes
January 8, 2021

The management of patients presenting to hospital emergency departments (EDs) with chest pain could be streamlined considerably thanks to new research led by a Royal Perth Hospital trainee.

Cardiology registrar Cara Barnes has found that under the current guideline-recommended pathway many of these patients undergo unnecessary testing and delays.

Her research has shown that most could undergo fewer tests and be discharged sooner without compromising their safety.

Dr Barnes said that although only about five per cent of the millions of patients presenting to EDs worldwide each year with chest pain would be experiencing symptoms due to a life-threatening condition, hospitals generally followed a relatively long and resource-intensive recommended pathway for the majority of these patients.

“This is due to the potential implications of missing a patient who is having a heart attack or has another life-threatening condition,” she explained.

“But our research has demonstrated that these pathways, which can involve several hours of observation and multiple blood tests, are often unnecessary.

“We can achieve the same results using a new faster pathway which relies on a single but highly sensitive blood test.”

The test checks for a protein called troponin which, if elevated, is a marker for heart problems.

“This test enables us to identify high-risk patients – who need admission and sometimes urgent treatment – much sooner,” Dr Barnes said.

“It can also be used to identify very low-risk patients who we can usually treat and discharge much sooner.

Earlier studies suggested that patients presenting to ED with chest pain but extremely low levels of troponin in their blood and no other concerning features, were at very low risk of having a heart attack.

“These patients would likely be suitable for earlier discharge without need for prolonged observation and more blood tests,” Dr Barnes said.

“These promising initial data, however, were based on reports of outcomes among patients who were kept under observation over a few hours and had further tests performed.”

“Our study actually implemented the faster novel strategy for patients in the Royal Perth ED in 2019 – enabling us to confirm that it does reduce unnecessary testing and delays without compromising patient safety.”

In their soon-to-be-published paper, Dr Barnes and her co-researchers reveal that while 38 per cent of patients managed using conventional methods were discharged within three hours of presentation, 63 per cent of those managed using the novel strategy achieved discharge within three hours.

Similarly, the median period under observation for patients managed as usual was 4.3 hours, compared with 3.6 hours for those assigned to the novel pathway.

Despite these differences, 30 days after their initial emergency department presentation, no patients discharged directly from the ED in either group had died or suffered a heart attack.

Dr Barnes said the results of her research could have significant implications for both patients and the health system.

The findings – which have since been implemented at Royal Perth Hospital – could pave the way for a simpler and less protracted process for millions of patients who present to EDs worldwide with chest pain. They could also lead to significant savings across the health system and free up valuable resources.

Dr Barnes’ project was funded via two WA health funding opportunities – a Registrar Research Fellowship which provided her with time away from her clinical duties to pursue the research – and a Research Translation Project grant.