HEART score improves efficiency of coronary computed tomography angiography in patients suspected of acute coronary syndrome in the emergency department

Impact of HEART Score Decision Aid on Coronary Computed Tomography Angiography Utilization and Diagnostic Yield in the Emergency Department

OBJECTIVE

Emergency physicians are challenged to efficiently and reliably risk stratify patients presenting with chest pain (CP) to optimize diagnostic testing and avoid unnecessary hospital admissions. The objective of our study was to evaluate the impact of a HEART score-based decision aid (HSDA) integrated in the electronic health record on coronary computed tomography angiography (CCTA) utilization and diagnostic yield in adult emergency department (ED) CP patients with suspected acute coronary syndrome.

METHODS

We conducted a before and after study to determine whether implementation of a mandatory computerized HSDA would reduce CCTA utilization in ED CP patients and improve the diagnostic yield of obstructive coronary artery disease (CAD) (≥50%). We included all adult ED CP patients with suspected acute coronary syndrome during the first 6 months of 2018 (before) and 2020 (after) at a large academic center. CCTA utilization and obstructive CAD yield were compared in patients before and after implementing the HSDA using χ2 tests. Secondarily, we assessed the association of HEART scores and CCTA results.

RESULTS

Of the 3095 CP patients during the before study period, 733 underwent CCTA. Of the 2692 CP patients during the after study period, 339 underwent CCTA. CCTA utilization before and after HSDA was 23.4% [95% confidence interval (95% CI), 22.2-25.2] and 12.6% (95% CI, 11.4-13.0), respectively; mean difference was 11.1% (95% CI, 0.9-13.0). Among 1072 patients undergoing CCTA, mean (SD) age and percent females before versus after HSDA were 54 (11) versus 56 (11) years and 50% versus 49%, respectively. We included 1014 patients (686 before and 328 after) for the yield analysis. Obstructive CAD was present in 15% (95% CI, 12.7-17.9) and 20.1% (95% CI, 16.1-24.7) before and after HSDA, respectively; mean difference was 4.9% (95% CI, 0.1-10.1).

CONCLUSIONS

Implementation of a mandatory electronic health record HSDA aid reduced ED CCTA utilization by half and improved the diagnostic yield.

Feasibility and Impact of the Combined Application of Coronary CT Angiography With the HEART Pathway in Patients With Suspected Acute Coronary Syndrome

BACKGROUND

This study examines the feasibility and utility of integrating coronary computed tomography angiography and the HEART Pathway into a novel accelerated diagnostic protocol-called HEART-CT-and assesses its impact as an optional interactive decision support tool (smart form) in the electronic health record.

METHODS

This was a retrospective observational study performed in 2 adult emergency departments (ED) among patients evaluated for suspected acute coronary syndrome. Primary outcomes included the rate of discharge from the ED following HEART-CT Smart Form use, 30-day major adverse cardiac events (MACE), and ED length of stay (LOS). Hypothesis-generating outcomes included the rate of Smart Form use by ED providers and whether adhering to the HEART-CT recommendations was associated with improved outcomes.

RESULTS

The study included 672 subjects, 78.1% of whom were discharged from the ED. HEART-CT identified 76.7% of patients with increased risk HEAR scores as safe for discharge. No patients identified as low risk by HEART-CT had MACE within 30 days. Total mean ED LOS was 4.6 hours. ED providers used the HEART-CT smart form in 19.7% of eligible patients. ED providers who followed the HEART-CT recommendations had 3.41 times higher odds of ED discharging patients with increased risk HEAR scores than nonadherent providers (95% CI, 2.20-5.27).

CONCLUSIONS

HEART-CT reclassified a large proportion of patients as safe for discharge, maintained a high sensitivity for detecting 30-day MACE, and had an acceptable ED LOS. Future studies should test the extent to which more automated clinical decision support improves provider adoption and clinical outcomes of HEART-CT.

Modification of the HEART pathway by adding coronary computed tomography angiography for patients suspected of acute coronary syndrome in the emergency department

The HEART (history, ECG, age, risk factors, troponin) pathway (HP) was developed for identifying low-risk patients for early discharge among patients presenting with chest pain to the emergency department (ED). We investigated whether adding coronary computed tomography angiography (CCTA) results to selected patients could improve the diagnostic accuracy of the HP. Patients suspected of acute coronary syndrome who had undergone CCTA were included. The HP was modified by adding CCTA results of stenosis of any major epicardial coronary arteries to patients either with 0-3 points and a positive troponin test or with 4-6 points. All patients were reclassified into low and increased risk groups. We then compared the accuracy of the modified HP, the HP, and the HEART score. The primary outcome was the 30-day major adverse cardiac events (MACE). Of the total 1239 patients included, MACE occurred in 206 (16.6%) patients. Adding the CCTA results increased the proportion of patients with low risk (68.7%) compared with the HP (40.0%) and the HEART score (47.4%). Using the modified HP, 50.4% of patients with intermediate-risk by the HEART score could be discharged from the ED and had no MACE. Incorporation of CCTA results improved the accuracy rate for the prediction of MACE compared with the HP and the HEART score (net reclassification improvements were 34.5 and 39.6%, respectively). Using the CCTA after the HP in selected patients could be a better strategy to discharge more patients early and safely.

lncRNA-MALAT1 expression in patients with coronary atherosclerosis and its predictive value for in-stent restenosis

This study was designed to investigate the long non-coding RNA (lncRNA)-metastasis associated lung adenocarcinoma transcript 1 (MALAT1) expression in patients with coronary atherosclerosis and its predictive value for in-stent restenosis. Ninety-five patients with coronary heart disease who came to our hospital for treatment and underwent stent implantation were selected as a research group (RG), and 95 volunteers undergoing physical examination who did not suffer from coronary heart disease during the same period were selected as a control group (CG). MALAT1 of subjects in both groups before and after treatment were detected by RT-qPCR, and N-terminal pro-brain natriuretic peptide (NT-proBNP), high sensitivity C-reactive protein (hs-CRP), lactate dehydrogenase (LDH), and creatine kinase isoenzyme (CK-MB) of them in the RG before treatment were detected. The level was evaluated and detected, and its correlation with MALAT1 was analyzed. Then, the predictive value of MALAT1 for in-stent restenosis in patients with coronary heart disease was analyzed. MALAT1 expression in patients with coronary heart disease was higher than that of normal subjects (P<0.05); after treatment, the expression levels of MALAT1, NT-proBNP, hs-CRP, LDH, and CK-MB in the serum of patients were significantly lower than those before treatment (P<0.05); MALAT1 expression was positively correlated with the expression levels of NT-proBNP, hs-CRP, LDH, and CK-MB (P<0.05). Receiver operating characteristic of MALAT1 for predicting in-stent restenosis in patients with coronary heart disease was over 0.8; the number of lesions, MALAT1, diabetes, NT-proBNP and hs-CRP were independent risk factors for in-stent restenosis. MALAT1 is highly expressed in the serum of patients with coronary heart disease, and it has high value in its diagnosis and the prediction of in-stent restenosis. It is also an independent risk factor for in-stent restenosis in patients with coronary heart disease.

Impact of Education-based HEART Score Pathway on Coronary Computed Tomography Angiography Utilization and Yield in the Emergency Department

OBJECTIVE

There is a growing consensus to reduce unnecessary testing among low-risk chest pain patients. The objective of this study was to evaluate the impact of implementing an education-based HEART score pathway in the emergency department on coronary computed tomography angiography (CCTA) utilization and yield.

METHODS

A retrospective before and after intervention study was conducted at a single site. Adult emergency department patients undergoing CCTA for suspected acute coronary syndrome were included. Primary outcomes were CCTA utilization and yield. Utilization was defined as the percentage of patients evaluated with CCTA and yield was calculated as the percentage of patients with a diagnosis of obstructive coronary artery disease, defined as ≥50% stenosis in any one coronary artery due to atherosclerosis.

RESULTS

1540 patients undergoing CCTAs were included. CCTA utilization before and after were 2.2% [95% confidence interval (CI) 2.0-2.3] and 2.0% (95% CI 1.9-2.2), respectively; mean difference 0.1% (95% CI -0.1 to 0.3; P = 0.21). The mean age was 53 years (SD = 11) and females were 52%. Of 1477 patients included in CCTA yield analysis, patients diagnosed with obstructive coronary artery disease before and after were 15.0% (95% CI 12.6-17.7) and 16.2% (95% CI 13.6-19.1), respectively; mean difference 1.2% (95% CI -2.6 to 5.1; P = 0.53).

CONCLUSIONS

There was no significant change in the CCTA utilization or yield after the implementation of an education-based HEART pathway in a large academic center. Our findings suggest adopting a more comprehensive approach for deploying such evidence-based protocols to increase institutional compliance.