The Diagnostic Accuracy of the Emergency Department Assessment of Chest Pain (EDACS) Score: A Systematic Review and Meta-analysis

Are medical history data fit for risk stratification of patients with chest pain in emergency care? Comparing data collected from patients using computerized history taking with data documented by physicians in the electronic health record in the CLEOS-CPDS prospective cohort study

OBJECTIVE

In acute chest pain management, risk stratification tools, including medical history, are recommended. We compared the fraction of patients with sufficient clinical data obtained using computerized history taking software (CHT) versus physician-acquired medical history to calculate established risk scores and assessed the patient-by-patient agreement between these 2 ways of obtaining medical history information.

MATERIALS AND METHODS

This was a prospective cohort study of clinically stable patients aged ≥ 18 years presenting to the emergency department (ED) at Danderyd University Hospital (Stockholm, Sweden) in 2017-2019 with acute chest pain and non-diagnostic ECG and serum markers. Medical histories were self-reported using CHT on a tablet. Observations on discrete variables in the risk scores were extracted from electronic health records (EHR) and the CHT database. The patient-by-patient agreement was described by Cohen's kappa statistics.

RESULTS

Of the total 1000 patients included (mean age 55.3 ± 17.4 years; 54% women), HEART score, EDACS, and T-MACS could be calculated in 75%, 74%, and 83% by CHT and in 31%, 7%, and 25% by EHR, respectively. The agreement between CHT and EHR was slight to moderate (kappa 0.19-0.70) for chest pain characteristics and moderate to almost perfect (kappa 0.55-0.91) for risk factors.

CONCLUSIONS

CHT can acquire and document data for chest pain risk stratification in most ED patients using established risk scores, achieving this goal for a substantially larger number of patients, as compared to EHR data. The agreement between CHT and physician-acquired history taking is high for traditional risk factors and lower for chest pain characteristics.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT03439449.

Performance of Manchester Acute Coronary Syndromes decision rules in acute coronary syndrome: a systematic review and meta-analysis

BACKGROUND AND IMPORTANCE

Multiple decision-aiding models are available to help physicians identify acute coronary syndrome (ACS) and accelerate the decision-making process in emergency departments (EDs).

OBJECTIVE

This study evaluates the diagnostic performance of the Manchester Acute Coronary Syndrome (MACS) rule and its derivations, enhancing the evidence for their clinical use.

DESIGN

Systematic review and meta-analysis.

SETTINGS AND PARTICIPANTS

Medline, Embase, Scopus, and Web of Science were searched from inception until October 2023 for studies including adult ED patients with suspected cardiac chest pain and inconclusive findings requiring ACS risk-stratification.

OUTCOME MEASURES AND ANALYSIS

The predictive value of MACS, Troponin-only MACS (T-MACS), or History and Electrocardiogram-only MACS (HE-MACS) decision aids for diagnosing acute myocardial infarction (AMI) and 30-day major adverse cardiac outcomes (MACEs) among patients admitted to ED with chest pain suspected of ACS. Overall sensitivity and specificity were synthesized using the 'Diagma' package in STATA statistical software. Applicability and risk of bias assessment were performed using the QUADAS-2 tool.

MAIN RESULTS

For AMI detection, MACS has a sensitivity of 99% [confidence interval (CI): 97-100], specificity of 19% (CI: 10-32), and AUC of 0.816 (CI: 0.720-0.885). T-MACS shows a sensitivity of 98% (CI: 98-99), specificity of 35% (CI: 29-42), and AUC of 0.859 (CI: 0.824-0.887). HE-MACS exhibits a sensitivity of 99% (CI: 98-100), specificity of 9% (CI: 3-21), and AUC of 0.787 (CI: 0.647-0.882). For MACE detection, MACS demonstrates a sensitivity of 98% (CI: 94-100), specificity of 22% (CI: 10-42), and AUC of 0.804 (CI: 0.659-0.897). T-MACS displays a sensitivity of 96% (CI: 94-98), specificity of 36% (CI: 30-43), and AUC of 0.792 (CI: 0.748-0.830). HE-MACS maintains a sensitivity of 99% (CI: 97-99), specificity of 10% (CI 6-16), and AUC of 0.713 (CI: 0.625-0.787).

CONCLUSION

Of all the MACS models, T-MACS displayed the highest overall accuracy due to its high sensitivity and significantly superior specificity. T-MACS exhibits very good diagnostic performance in predicting both AMI and MACE. This makes it a highly promising tool for managing patients with acute chest pain.

Assessment and Application of the Hear Score in Remote Emergency Medicine Outposts in Bosnia and Herzegovina

Background and Objectives. In emergency departments, chest pain is a common concern, highlighting the critical importance of distinguishing between acute coronary syndrome and other potential causes. Our research aimed to introduce and implement the HEAR score, specifically, in remote emergency outposts in Bosnia and Herzegovina. Materials and Methods. This follow-up study conducted a retrospective analysis of a prospective cohort consisting of patients who were admitted to the remote emergency medicine outposts in Canton Sarajevo and Zenica from 1 November to 31 December 2023. Results. This study comprised 103 (12.9%) patients with low-risk HEAR scores and 338 (83.8%) with high-risk HEAR scores, primarily female (221, 56.9%), with a mean age of 63.5 ± 11.2). Patients with low-risk HEAR scores were significantly younger (50.5 ± 15.6 vs. 65.9 ± 12.1), had fewer smokers (p < 0.05), and exhibited a lower incidence of cardiovascular risk factors compared to those with high-risk HEAR scores. Low-risk HEAR score for prediction of AMI had a sensitivity of 97.1% (95% CI 89.9-99.6%); specificity of 27.3% (95% CI 22.8-32.1%); PPV of 19.82% (95% CI 18.67-21.03%), and NPV of 98.08% (95% CI 92.80-99.51%). Within 30 days of the admission to the emergency department outpost, out of all 441 patients, 100 (22.7%) were diagnosed with MACE, with AMI 69 (15.6%), 3 deaths (0.7%), 6 (1.4%) had a CABG, and 22 (4.9%) underwent PCI. A low-risk HEAR score had a sensitivity of 97.0% (95% CI 91.7-99.4%) and specificity of 27.3% (95% CI 22.8-32.1%); PPV of 25.5% (95% CI 25.59-28.37%); NPV of 97.14% (95% CI 91.68-99.06%) for 30-day MACE. Conclusions. In conclusion, the outcomes of this study align with existing research, underscoring the effectiveness of the HEAR score in risk stratification for patients with chest pain. In practical terms, the implementation of the HEAR score in clinical decision-making processes holds significant promise.

Musculoskeletal chest pain prevalence in emergency department presentations: A retrospective case notes review

OBJECTIVE

Musculoskeletal (MSK) causes of chest pain are considered common in emergency care, yet management is limited, reported outcomes are poor and prevalence data in New Zealand are lacking. The present study aims to estimate the prevalence of MSK chest pain in New Zealand EDs and describe the characteristics of MSK chest pain cases.

METHODS

A retrospective chart review was conducted based on de-identified clinical notes extracted from four hospitals within the South Island of New Zealand from 3 months spanning 1 March to 31 May 2021. Individual cases were categorised to the single best-fitting cause of chest pain using systems-based categorisation, based primarily on the doctors' documented final impression.

RESULTS

A total of 1344 cases were categorised in the present study. MSK chest pain had a prevalence of 15% (range 11-31%) of chest pain presentations across all study sites. This represented the second most common system responsible for chest pain, after the cardiovascular system. The mean age of MSK chest pain cases was 46.9 (standard deviation [SD] 19.1) years, compared to 55.5 (SD 19.7) years in all cases. Age and gender-specific data, data from rural hospitals and MSK sub-type data are presented.

CONCLUSIONS

These data provide a conservative estimate of MSK chest pain prevalence in EDs within the South Island of New Zealand. The findings highlight MSK chest pain as common in emergency care, providing a basis and justification for further research to improve management and outcomes for people with MSK chest pain.

Flexible-Interval High-Sensitivity Troponin Velocity for the Detection of Acute Coronary Syndromes

Many algorithms for emergency department (ED) evaluation of acute coronary syndrome (ACS) using high-sensitivity troponin assays rely on the detection of a "delta," the difference in concentration over a predetermined interval, but collecting specimens at specific times can be difficult in the ED. We evaluate the use of troponin "velocity," the rate of change of troponin concentration over a flexible short interval for the prediction of major adverse cardiac events (MACEs) at 30 days. We conducted a prospective, observational study on a convenience sample of 821 patients who underwent ACS evaluation at a high-volume, urban ED. We determined the diagnostic performance of a novel velocity-based algorithm and compared the performance of 1- and 2-hour algorithms adapted from the European Society of Cardiology (ESC) using delta versus velocity. A total of 7 of 332 patients (2.1%) classified as low risk by the velocity-based algorithm experienced a MACE by 30 days compared with 35 of 221 (13.8%) of patients classified as greater than low risk, yielding a sensitivity of 83.3% (95% confidence interval [CI] 68.6% to 93.0%) and negative predictive value (NPV) of 97.9% (95% CI 95.9% to 98.9%). The ESC-derived algorithms using delta or velocity had NPVs ranging from 98.4% (95% CI 96.4% to 99.3%) to 99.6% (95% CI 97.0% to 99.9%) for 30-day MACEs. The NPV of the novel velocity-based algorithm for MACE at 30 days was borderline, but the substitution of troponin velocity for delta in the framework of the ESC algorithms performed well. In conclusion, specimen collection within strict time intervals may not be necessary for rapid evaluation of ACS with high-sensitivity troponin.

HEART Score and Its Implementation in Emergency Medicine Departments in the West Balkan Region-A Pilot Study

BACKGROUND

Chest pain represents a prevalent complaint in emergency departments (EDs), where the precise differentiation between acute coronary syndrome and alternative conditions assumes paramount significance. This pilot study aimed to assess the HEART score's implementation in West Balkan EDs.

METHODS

A retrospective analysis was performed on a prospective cohort comprising patients presenting with chest pain admitted to EDs in Sarajevo, Zenica, and Belgrade between July and December 2022.

RESULTS

A total of 303 patients were included, with 128 classified as low-risk based on the HEART score and 175 classified as moderate-to-high-risk. The low-risk patients exhibited younger age and a lower prevalence of cardiovascular risk factors. Laboratory and anamnestic findings revealed higher levels of C-reactive protein, ALT, and creatinine, higher rates of moderately to highly suspicious chest pain history, a greater number of cardiovascular risk factors, and elevated troponin levels in moderate-to-high-risk patients. Comparatively, among patients with a low HEART score, 2.3% experienced MACE, whereas those with a moderate-to high-risk HEART score had a MACE rate of 10.2%. A moderate-to-high-risk HEART score demonstrated a sensitivity of 91.2% (95%CI 90.2-93.4%) and specificity of 46.5% (95%CI 39.9-48.3%) for predicting MACE.

CONCLUSION

This pilot study offers preliminary insights into the integration of the HEART score within the emergency departments of the West Balkan region.

Improved prehospital triage for acute cardiac care: results from HART-c, a multicentre prospective study

BACKGROUND

Cardiac symptoms are one of the most prevalent reasons for emergency department visits. However, over 80% of patients with such symptoms are sent home after acute cardiovascular disease has been ruled out.

OBJECTIVE

The Hollands-Midden Acute Regional Triage-cardiology (HART-c) study aimed to investigate whether a novel prehospital triage method, combining prehospital and hospital data with expert consultation, could increase the number of patients who could safely stay at home after emergency medical service (EMS) consultation.

METHODS

The triage method combined prehospital EMS data, such as electrocardiographic and vital parameters in real time, and data from regional hospitals (including previous medical records and admission capacity) with expert consultation. During the 6‑month intervention and control periods 1536 and 1376 patients, respectively, were consulted by the EMS. The primary endpoint was the percentage change of patients who could stay at home after EMS consultation.

RESULTS

The novel triage method led to a significant increase in patients who could safely stay at home, 11.8% in the intervention group versus 5.9% in the control group: odds ratio 2.31 (95% confidence interval (CI) 1.74-3.05). Of 181 patients staying at home, only 1 (< 1%) was later diagnosed with ACS; no patients died. Furthermore the number of interhospital transfers decreased: relative risk 0.81 (95% CI 0.67-0.97).

CONCLUSION

The HART‑c triage method led to a significant decrease in interhospital transfers and an increase in patients with cardiac symptoms who could safely stay at home. The presented method thereby reduced overcrowding and, if implemented throughout the country and for other medical specialties, could potentially reduce the number of cardiac and non-cardiac hospital visits even further.

An international, stepped wedge, cluster-randomized trial investigating the 0/1-h algorithm in suspected acute coronary syndrome in Asia: the rational of the DROP-Asian ACS study

BACKGROUND

More than half of the world's population lives in Asia. With current life expectancies in Asian countries, the burden of cardiovascular disease is increasing exponentially. Overcrowding in the emergency departments (ED) has become a public health problem. Since 2015, the European Society of Cardiology recommends the use of a 0/1-h algorithm based on high-sensitivity cardiac troponin (hs-cTn) for rapid triage of patients with suspected non-ST elevation acute coronary syndrome (NSTE-ACS). However, these algorithms are currently not recommended by Asian guidelines due to the lack of suitable data.

METHODS

The DROP-Asian ACS is a prospective, stepped wedge, cluster-randomized trial enrolling 4260 participants presenting with chest pain to the ED of 12 acute care hospitals in five Asian countries (UMIN; 000042461). Consecutive patients presenting with suspected acute coronary syndrome between July 2022 and Apr 2024 were included. Initially, all clusters will apply "usual care" according to local standard operating procedures including hs-cTnT but not the 0/1-h algorithm. The primary outcome is the incidence of major adverse cardiac events (MACE), the composite of all-cause death, myocardial infarction, unstable angina, or unplanned revascularization within 30 days. The difference in MACE (with one-sided 95% CI) was estimated to evaluate non-inferiority. The non-inferiority margin was prespecified at 1.5%. Secondary efficacy outcomes include costs for healthcare resources and duration of stay in ED.

CONCLUSIONS

This study provides important evidence concerning the safety and efficacy of the 0/1-h algorithm in Asian countries and may help to reduce congestion of the ED as well as medical costs.

Risk stratification of patients who present with chest pain and have normal troponins using a machine learning model

BACKGROUND

Risk stratification tools exist for patients presenting with chest pain to the emergency room and have achieved the recommended negative predictive value (NPV) of 99%. However, due to low positive predictive value (PPV), current stratification tools result in unwarranted investigations such as serial laboratory tests and cardiac stress tests (CSTs).

AIM

To create a machine learning model (MLM) for risk stratification of chest pain with a better PPV.

METHODS

This retrospective cohort study used de-identified hospital data from January 2016 until November 2021. Inclusion criteria were patients aged > 21 years who presented to the ER, had at least two serum troponins measured, were subsequently admitted to the hospital, and had a CST within 4 d of presentation. Exclusion criteria were elevated troponin value (> 0.05 ng/mL) and missing values for body mass index. The primary outcome was abnormal CST. Demographics, coronary artery disease (CAD) history, hypertension, hyperlipidemia, diabetes mellitus, chronic kidney disease, obesity, and smoking were evaluated as potential risk factors for abnormal CST. Patients were also categorized into a high-risk group (CAD history or more than two risk factors) and a low-risk group (all other patients) for comparison. Bivariate analysis was performed using a χ² test or Fisher’s exact test. Age was compared by t test. Binomial regression (BR), random forest, and XGBoost MLMs were used for prediction. Bootstrapping was used for the internal validation of prediction models. BR was also used for inference. Alpha criterion was set at 0.05 for all statistical tests. R software was used for statistical analysis.

RESULTS

The final cohort of the study included 2328 patients, of which 245 (10.52%) patients had abnormal CST. When adjusted for covariates in the BR model, male sex [risk ratio (RR) = 1.52, 95% confidence interval (CI): 1.2-1.94, P < 0.001)], CAD history (RR = 4.46, 95%CI: 3.08-6.72, P < 0.001), and hyperlipidemia (RR = 3.87, 95%CI: 2.12-8.12, P < 0.001) remained statistically significant. Incidence of abnormal CST was 12.2% in the high-risk group and 2.3% in the low-risk group (RR = 5.31, 95%CI: 2.75-10.24, P < 0.001). The XGBoost model had the best PPV of 24.33%, with an NPV of 91.34% for abnormal CST.

CONCLUSION

The XGBoost MLM achieved a PPV of 24.33% for an abnormal CST, which is better than current stratification tools (13.00%-17.50%). This highlights the beneficial potential of MLMs in clinical decision-making.

High-Sensitivity Cardiac Troponin T and the Diagnosis of Cardiovascular Disease in the Emergency Room: The Importance of Combining Cardiovascular Biomarkers with Clinical Data

Background. Nowadays, it is still not possible to clinically distinguish whether an increase in high-sensitivity cardiac troponin (hs-cTn) values is due to myocardial injury or an acute coronary syndrome (ACS). Moreover, predictive data regarding hs-cTnT in an emergency room (ER) setting are scarce. This monocentric retrospective study aimed to improve the knowledge and interpretation of this cardiac biomarker in daily clinical practice. Methods. Consecutive adult patients presenting at the ER and hospitalized with a first abnormal hs-cTnT value (≥14 ng/L) were enrolled for 6 months. The baseline hs-cTnT value and the ensuing changes and variations were correlated with the clinical presentation and the type of diagnosis. Subsequently, multivariable models were built to assess which clinical/laboratory variables most influenced hospital admissions in the investigated population analyzed according to the final reason for hospitalization: (1) cardiovascular vs. non-cardiovascular diagnosis, and (2) ACS vs. non-ACS one. Results. A total of 4660 patients were considered, and, after a first screening, 4149 patients were enrolled. Out of 4129 patients, 1555 (37.5%) had a first hs-cTnT ≥14 ng/L, and 1007 (65%) were hospitalized with the following types of diagnosis: ACS (182; 18%), non-ACS cardiovascular disease (337; 34%) and non-cardiovascular disease (487; 48%). Higher hs-cTnT values and significant hs-cTnT variations were found in the ACS group (p < 0.01). The mean percentage of variation was higher in patients with ACS, intermediate in those with non-ACS cardiovascular disease, and low in those with non-cardiovascular disease (407.5%, 270.6% and 12.4%, respectively). Only syncope and CRP (OR: 0.08, 95% CI: 0.02−0.39, p < 0.01 and OR: 0.9988, 95% CI: 0.9979−0.9998, p = 0.02, respectively) or CRP (OR: 0.9948, 95% CI: 0.9908−0.9989, p = 0.01) and NT-proBNP (OR: 1.0002, 95% CI: 1.0000−1.0004, p = 0.02) were independent predictors of a cardiovascular disease diagnosis. On the other hand, only chest pain (OR: 22.91, 95% CI: 3.97−132.32, p < 0.01) and eGFR (OR: 1.04, 95% CI: 1.004−1.083, p = 0.03) were associated with the ACS diagnosis. Conclusions. Differently from the investigated biomarkers, in this study, only clinical variables predicted hospitalizations in different patients’ subgroups.

Early discharging patients with chest pain using EDACS-ADP and COMPASS-MI risk predictors

Deciding on the early discharge of low-risk patients with chest pain is still controversial in emergency care. Beyond the validated tools for risk assessment, high sensitive troponin levels on admission, whether to take the next serial sampling or when to take are the main issues affecting the unnecessary follow-ups that lead to the emergency crowd. We aimed to investigate the prediction performance of emergency department assessment of chest pain score and accelerated diagnostic protocol (EDACS-ADP) and calculation of MI risk probabilities to manage patients with suspicion of myocardial infarction (COMPASS-MI). We conducted a prospective cross-sectional study that included patients with chest pain followed-up in the emergency department with a serial troponin sampling. We calculated the performance tests of the risk scores after recording the patients' risk factors, chest pain types, troponin levels as defined in the risk assessment tools. Nine hundred eleven patients were included in the study. Thirty-eight patients had significant adverse cardiovascular events (MACE) within 30 days. Patients with a not-low-risk score at EDACS-ADP had a 3.975 (95% CI 2.136–7.396) fold higher risk of MACE than the patients with low-risk EDACS-ADP, and the absolute risk increase was 7.3%. Patients with high-risk late-stage risk in COMPASS-MI had a 3.581 (95% CI 1.660–7.726) fold higher risk of MACE than those with low-risk late-stage risk in COMPASS-MI, and absolute risk increase was 4.6%. We found EDACS-ADP and COMPASS-MI at a late time point (2 h hsTnI) with a high negative predictive value as a risk assessment tool for discharging chest pain patients.

Effect of the Emergency Department Assessment of Chest Pain Score on the Triage Performance in Patients With Chest Pain

The sensitivity of triage systems in identifying acute cardiovascular events in patients presented to the emergency department with chest pain is not optimal. Recently, a clinical score, the Emergency Department Assessment of Chest Pain Score (EDACS), has been proposed for a rapid assessment without additional instruments. To evaluate whether the integration of EDACS into triage evaluation of patients with chest pain can improve the triage's predictive validity for an acute cardiovascular event, a single-center prospective observational study was conducted. This study involved all patients who needed a triage admission for chest pain between January 1, 2020, and December 31, 2020. All enrolled patients first underwent a standard triage assessment and then the EDACS was calculated. The primary outcome of the study was the presence of an acute cardiovascular event. The discriminatory ability of EDACS in triage compared with standard triage assessment was evaluated by comparing the areas under the receiver operating characteristic curve, decision curve analysis, and net reclassification improvement. The study involved 1,596 patients, of that 7.3% presented the study outcome. The discriminatory ability of triage presented an area under the receiver operating characteristic curve of 0.688 that increased to 0.818 after the application of EDACS in the triage assessment. EDACS improved the baseline assessment of priority assigned in triage, with a net reclassification improvement of 33.6% (p <0.001), and the decision curve analyses demonstrated that EDACS in triage resulted in a clear net clinical benefit. In conclusion, the results of the study suggest that EDACS has a good discriminatory capacity for acute cardiovascular events and that its implementation in routine triage may improve triage performance in patients with chest pain.

Graded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort Study

Background Resource utilization among emergency department (ED) patients with possible coronary chest pain is highly variable. Methods and Results Controlled cohort study amongst 21 EDs of an integrated healthcare system examining the implementation of a graded coronary risk stratification algorithm (RISTRA-ACS [risk stratification for acute coronary syndrome]). Thirteen EDs had access to RISTRA-ACS within the electronic health record (RISTRA sites) beginning in month 24 of a 48-month study period (January 2016 to December 2019); the remaining 8 EDs served as contemporaneous controls. Study participants had a chief complaint of chest pain and serum troponin measurement in the ED. The primary outcome was index visit resource utilization (observation unit or hospital admission, or 7-day objective cardiac testing). Secondary outcomes were 30-day objective cardiac testing, 60-day major adverse cardiac events (MACE), and 60-day MACE-CR (MACE excluding coronary revascularization). Difference-in-differences analyses controlled for secular trends with stratification by estimated risk and adjustment for risk factors, ED physician and facility. A total of 154 914 encounters were included. Relative to control sites, 30-day objective cardiac testing decreased at RISTRA sites among patients with low (≤2%) estimated 60-day MACE risk (-2.5%, 95% CI -3.7 to -1.2%, P<0.001) and increased among patients with non-low (>2%) estimated risk (+2.8%, 95% CI +0.6 to +4.9%, P=0.014), without significant overall change (-1.0%, 95% CI -2.1 to 0.1%, P=0.079). There were no statistically significant differences in index visit resource utilization, 60-day MACE or 60-day MACE-CR. Conclusions Implementation of RISTRA-ACS was associated with better allocation of 30-day objective cardiac testing and no change in index visit resource utilization or 60-day MACE. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03286179.

A Methodological Appraisal of the HEART Score and Its Variants

We performed a methodological appraisal of the history, electrocardiogram, age, risk factors, and troponin (HEART) score and its variants in the context of Annals of Emergency Medicine's methodological standards for clinical decision rules. We note that this chest pain risk stratification tool was not formally derived, omits sex and other known predictors, has weak interrater reliability, and its 0, 1, and 2 score weightings do not align with their known predictivities. Its summary performance (pooled sensitivities of 96% to 97% with lower confidence interval bounds of 93% to 94%) is below that which emergency physicians state a willingness to accept, below the 98% sensitivity exhibited by baseline practice without the score, and below the 1% to 2% acceptable miss threshold specified by the American College of Emergency Physicians chest pain policy. Two variants (HEART Pathway, HEART-2) have the same inherent structural limitations and demonstrate slightly better but still suboptimal sensitivity. Although a simple prediction tool for chest pain outcomes is appealing, we believe that the widespread use of the HEART score and its variants should be reconsidered.