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Objectives and BackgroundsCurrent diagnostic strategies using cardiac markers in the assessment of suspected acute coronary syndrome (ACS) involve the measurement of serum troponin 10–12 h after the onset of chest pain. We evaluated the potential impact of a multimarker strategy using point of care (POC) measurement of myoglobin, creatine kinase (CK)-MB and troponin I to exclude MI in ≤90 min.MethodsPatients presenting to the Emergency Department with suspected ACS with non-diagnostic ECGs were included. We measured myoglobin, CK-MB and troponin I with a POC device at presentation and at 90 min. Standard laboratory testing of troponin I was performed at 12 h. Sensitivity, specificity and likelihood ratios for the POC triple cardiac marker strategy were calculated. We also calculated time to decision point for POC testing vs laboratory testing.ResultsComplete data were available for 109 patients. 73 patients had negative POC testing and normal laboratory troponin. POC markers were positive in 36 patients, of which 19 had positive 12 h laboratory troponin I. Sensitivity of POC cardiac markers was 100% (95% CI 0.79% to 1.0%), specificity 81% (95% CI 0.71% to 0.88%), negative likelihood ratio <0.001 and positive likelihood ratio 5.29. Mean time to decision point was 700 min earlier for POC testing vs laboratory troponin measurement. We estimate that implementation of the triple cardiac markers POC pathway in our institution would save 3 beds per day.ConclusionsTriple cardiac marker POC testing at 90 min can be used to reliably exclude acute myocardial infarction in patients with low to moderate risk ACS, and has the potential to reduce inpatient medical bed occupancy.

Background Strokes are frequently seen in older patients mainly due to long standing hypertension, diabetes mellitus and hyper cholesterolemia. It is not common in younger adults especially when there is no obvious cause. The workup to find the cause is often difficult in such cases. Case Description A 38-year-old paraplegic male presented in Emergency Department with the complaints of fever, headache, haematuria and awaiting closure of left hip wound; however, it seemed non infected. Regarding his medical history, he had ASD associated with pulmonary hypertension and type 1 diabetes mellitus. Besides, after 24hrs of admission he developed right sided neglect. On examination, he was febrile with increased heart rate and respiratory rate. Moreover, he had right homonymous hemianopia and NIHSS score was 3. CT PA was done to rule out pulmonary embolism. Additionally, CT CAP and CT head showed splenic infarct and occipital infarct, respectively. Therefore, a diagnosis of paradoxical embolus was made and treated accordingly. Later, blood culture revealed beta haemolytic streptococci and the underlying cause of septic stroke was thought to be hip ulcer extending to bone. This was followed by CT pelvis, on which bone destruction was seen. Therefore, antibiotics were commenced and left hemiarthoplasty was done. Conclusion This case illustrate that in younger population, often soft tissue and bone infection can lead to pro-thrombotic events resulting into septic emboli, a potential cause of stroke (especially when accompanied by ASD). Early assessment and management is valuable as it can lead to serious complications and increased morbidity.