• J Coates.
• Department of Critical Care, Queen Alexandra Hospital, Portsmouth, Hampshire, United Kingdom.
• Emerg Med J. 2013 Oct 1;30(10):870-1.

Objectives & BackgroundAdmissions to the Emergency Department with chest pain constitute a significant proportion of the work-load. In England it represents 6% of all Emergency Department (ED) attendances. These attendances translate to accounting for approximately 25% of acute medical admissions. One method of excluding myocardial infarction is the use of a rapid point of care Triple Cardiac Marker test. This allows testing at time point 0 and 90 minutes and negates the need for a delayed troponin. One of the markers, myoglobin, has a high sensitivity but low specificity. If there is a 25% rise in myoglobin between two tests then it is considered a positive result. The patient then requires a 12-hour troponin. Locally, there was concern over the value of including myoglobin in the triple test as it was felt that it lead to inappropriate admissions.MethodsThis was a retrospective case review. The Triage© Cardiac Panel machine from Alere records patient numbers and test results. Patient numbers and results were extracted over a continuous 8 month period. The Emergency Department notes were then interrogated and this was combined with data from the hospital pathology system, looking specifically for patients that were admitted on the basis of positive myoglobin result. Hospital notes were requested if points needed to be clarified.ResultsA total of 636 paired tests were analysed. 103 (16.3%) of patients had a positive myoglobin rise. The range of myoglobin rises can be seen in Figure 1. 100 notes were available, of which only 56 were admitted for a 12 hour troponin. 54 underwent 12 hour troponin testing and three were positive (5.6%). There appeared to be no correlation between the % rise in myoglobin and the rise in troponin. 44 patients were discharged after achieving a positive triple test result. 35 of these were felt to be inappropriate. 16 sets of notes reported mentioned somewhere that the triple test was "negative." The use of the chest pain proforma did not seem to improve the performance of the doctors-Figure 2. Abstract 011 Figure 1Range of Myoglobin Rises. Abstract 011 Figure 2Effect of completion of Chest Pain Protocol on patient disposition.ConclusionThe use of myoglobin in the triple test does appear to be appropriate for the local population. There is a significant short-coming in the application of the triple test that is putting patients at risk of an adverse outcome. The current chest pain proforma as it stands does not appear to prevent inappropriate discharges.

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