Interest of CARE Rule to Exclude the Hypothesis of an Acute Coronary Syndrome Without Bioassay - ICARE (ICARE)

• ClinicalTrials.gov Identifier: NCT02813499
• Recruitment Status: Completed
• First Posted: June 27, 2016
• Last Update Posted: April 6, 2018
• Sponsor: University Hospital, Angers
• Information provided by (Responsible Party): University Hospital, Angers

Study Description

Brief Summary:

Acute coronary syndrome (ACS) is a major health problem and its diagnosis remains a challenge for the emergency physician. The management of a suspected ACS is well codified, based on troponin assays, renewed if necessary.

Conversely, the criteria leading to initiate a diagnostic procedure in chest pain to the Emergency department are unclear. The fear is, firstly, to miss a potentially life treating diagnosis and, secondly, exposing many patients to unnecessary examinations. The advent of highly sensitive troponin assays also increases the risk of over-investigation by a larger number of elevations of the biomarker in non-coronary circumstances leading to a prolongation of hospitalization and, possibly, unnecessary treatments and invasive investigations.

CARE rule could help to streamline this first step. It is established by assigning a value from 0 to 2 to the items: Characteristic of pain, Age, Risk factors and ECG. The search for an ACS is not justified if the sum of points is ≤1 (negative rule) and, conversely, a troponin should be performed if the sum is > 1 (positive rule).

Indeed, CARE rule corresponds to the first 4 items of the HEART score (the latter standing for troponin at admission) whose reliability has been demonstrated, a ≤3 income excluding ACS with a risk of false negatives <2%. A negative CARE rule always corresponds to a HEART score ≤3.

Our study aims to confirm the interest of CARE rule to streamline the search for an ACS in chest pain as an observational European multicenter prospective study.

Condition or disease	Intervention/treatment
Chest Pain	Other: CARE Rule

Detailed Description:

CARE rule was evaluated in a prospective study of routine care on 641 patients among which 9.8% had a Major Adverse Cardiac Event (MACE). 200 patients (31%) had a negative rule and none showed MACE during the 45-day follow-up (0% [0-1.9]). Among these 200 patients, 119 had a standard troponin assay, a single dosage was increased.

The main objective is to demonstrate the reliability of CARE rule to exclude ACS in chest pain, using an observational Franco-Belgian multicenter study in routine care.

If the reliability of CARE rule is confirmed in Emergency departments, it could be evaluated to be used in other circumstances such as in pre-hospital or in private practice for the general practitioner or cardiologist.

In summary, the ICARE study is intended to allow a rationalization of the management of patients with chest pain, limiting the use of unnecessary investigations while ensuring the safety of care.

Study Design

• Study Type: Observational
• Actual Enrollment: 1453 participants
• Observational Model: Case-Only
• Time Perspective: Prospective
• Official Title: Intérêt de la règle CARE Pour Exclure l'hypothèse d'un Syndrome Coronarien Aigu Sans Dosage Biologique - ICARE
• Actual Study Start Date: November 2016
• Actual Primary Completion Date: January 2018
• Actual Study Completion Date: January 2018

Groups and Cohorts

Group/Cohort	Intervention/treatment
CARE Rule; Evaluation of the clinical suspicion of myocardial infarction and calculation of CARE rule.	Other: CARE Rule; Evaluation of the clinical suspicion of myocardial infarction, calculation of CARE rule and troponin assay performed by the practitioner.

Outcome Measures

Primary Outcome Measures :

1. The failure rate of the diagnostic strategy will be evaluated by the rate of MACE recorded in the course of the phone call follow-up at 45 days of patient's inclusion in the group of patients with negative CARE rule. [ Time Frame: Day 45 ]
   This rate is a composite criterion including myocardial infarction, percutaneaous coronary intervention, coronary artery bypass grafting or sudden death for which a cardiac cause cannot be excluded. The procedure will be considered acceptable if the rate of false negatives among patients with negative CARE rule is less than 1% with an upper limit of the 95% confidence interval lower than 3%.

Secondary Outcome Measures :

1. The failure rate of the HEART score only considering only one dosage of troponin at admission assessed by the proportion of MACE at 45 days in the HEART group ≤3 [ Time Frame: Day 45 ]
2. Number of bioassay which could be saved, measured by the difference between the number of bioassays actually made least the number bioassays requested by the strategy [ Time Frame: Day 45 ]
3. Difference between average times of consultation according to the need for a bioassay based on CARE rule [ Time Frame: Day 45 ]

Eligibility Criteria

• Ages Eligible for Study: 18 Years and older (Adult, Older Adult)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No
• Sampling Method: Non-Probability Sample

Study Population

Adults with non-traumatic chest pain

Criteria

Inclusion Criteria:

• patient admitted to the emergency department or chest pain
• patient admitted in a non-scheduled manner
• non-traumatic chest pain
• no formal diagnosis after frontline examinations

Exclusion Criteria:

• patient with an ECG showing a coronary syndrome ST +
• patient for which a 6-weeks follow-up would be impossible
• patient refusing to participate

Contacts and Locations

Locations

Belgium

Cliniques Universitaires Saint-Luc

Brussels, Belgium

France

University Hospital Angers

Angers, France, 49933

Hospital of Cholet

Cholet, France

SCHOTTE Thibault

Le Mans, France

Hospital of Saint-Malo

Saint Malo, France

University Hospital Toulouse

Toulouse, France

Sponsors and Collaborators

University Hospital, Angers

More Information

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):

Moumneh T, Penaloza A, Cismas A, Charpentier S, Schotte T, Pernet S, Malatest S, Prunier F, Warnant A, Mezdad TH, Gangloff C, Soulat L, Douillet D, Riou J, Roy PM. Evaluation of HEAR score to rule-out major adverse cardiac events without troponin test in patients presenting to the emergency department with chest pain. Eur J Emerg Med. 2021 Aug 1;28(4):292-298. doi: 10.1097/MEJ.0000000000000791.

• Responsible Party: University Hospital, Angers
• ClinicalTrials.gov Identifier: NCT02813499
• Other Study ID Numbers: AOI 2015-06
• First Posted: June 27, 2016
• Last Update Posted: April 6, 2018
• Last Verified: April 2018

• Studies a U.S. FDA-regulated Drug Product: No
• Studies a U.S. FDA-regulated Device Product: No

Keywords provided by University Hospital, Angers:

Acute Coronary Syndrome

Additional relevant MeSH terms:

Acute Coronary Syndrome; Chest Pain; Myocardial Ischemia; Heart Diseases; Cardiovascular Diseases; Vascular Diseases; Pain; Neurologic Manifestations