Systematic review, meta-analysis and economic modelling of diagnostic strategies for suspected acute coronary syndrome

Abstract

This journal is a member of and subscribes to the principles of the Committee on Publication Ethics (COPE) (http://www.publicationethics.org/).Editorial contact: nihredit@southampton.ac.ukThe full HTA archive is freely available to view online at http://www.hta.ac.uk/project/htapubs.asp. Print copies can be purchased from the individual report pages. criteria for inclusion in the Health Technology Assessment journalReports are published in Health Technology Assessment (HTA) if (1) they have resulted from work for the HTA programme, and (2) they are of a sufficiently high scientific quality as assessed by the reviewers and editors.Reviews in Health Technology Assessment are termed 'systematic' when the account of the search appraisal and synthesis methods (to minimise biases and random errors) would, in theory, permit the replication of the review by others. Hta programmeThe HTA programme, part of the National Institute for Health Research (NIHR), was set up in 1993. It produces high-quality research information on the effectiveness, costs and broader impact of health technologies for those who use, manage and provide care in the NHS. 'Health technologies' are broadly defined as all interventions used to promote health, prevent and treat disease, and improve rehabilitation and long-term care.The research findings from the HTA programme directly influence decision-making bodies such as the National Institute for Health and Clinical Excellence (NICE) and the National Screening Committee (NSC). HTA programme findings also help to improve the quality of clinical practice in the NHS indirectly in that they form a key component of the 'National Knowledge Service'.For more information about the HTA programme please visit the website: http://www.hta.ac.uk/ this reportThe research reported in this issue of the journal was funded by the HTA programme as project number 09/22/21. The contractual start date was in July 2010. The draft report began editorial review in January 2012 and was accepted for publication in June 2012. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HTA editors and publisher have tried to ensure the accuracy of the authors' report and would like to thank the reviewers for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this report.This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HTA programme or the Department of Health.

Randomised Assessment of Treatment using Panel Assay of Cardiac markers – Contemporary Biomarker Evaluation (RATPAC CBE)

“…This analysis is based on a model developed for a related project, 'Cost-effectiveness of diagnostic strategies for suspected acute coronary syndrome (ACS)' (HTA09/22/21), which used estimates of sensitivity and specificity for high-sensitivity troponin and H-FABP derived from a systematic literature review and meta-analysis. 241 The findings were similar, suggesting that a 10-hour troponin measurement is likely to be cost-effective only if a £30,000 per QALY threshold is used and the patient can be discharged as soon as the results are available. The combination of troponin with H-FABP or measurement of highsensitivity troponin at baseline and at 90 minutes were both potentially cost-effective, but estimates of sensitivity and specificity in each case were derived from one study.…”

“…241 Full details of the model are given in the HTA journal publication for this project, but the essential details are as follows.…”

ICare-ACS (Improving Care Processes for Patients With Suspected Acute Coronary Syndrome)

“…The observation and investigation of such patients are major health-system burdens. [1][2][3] Clinical guidelines and clinical pathways are increasingly being used in these situations in which clinical uncertainty may lead to inappropriate or unnecessary investigation.…”

“…They take into account factors such as resource availability and consensus of local subject matter experts. Clinical pathways are structured, multidisciplinary inventory of actions that meet any 3 of the following criteria: (1) are used to channel the translation of guidelines or evidence into local practices, (2) detail the steps in a course of treatment or care, (3) have a time frame or criteria-based progression (ie, steps are taken if or when designated criteria are met), or (4) aim to standardize care for a specific clinical problem or outcome. 5 Clinical pathways have been shown to reduce complications, decrease length of stay, and reduce hospital costs.…”

Rapidly rule out acute myocardial infarction by combining copeptin and heart-type fatty acid-binding protein with cardiac troponin

“…1 The ability to rapidly and accurately distinguish AMI from other causes of chest pain is crucial to the initiation of effective therapeutic strategies. 2 Moreover, because only approximately one in five patients who present to the emergency department (ED) with symptoms of AMI are actually diagnosed with AMI, [3][4][5] an accelerated rule out can free up valuable time from health-care providers and reduce the burden on health-care systems.…”