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Miller J, Cook B, Gandolfo C, Mills NL, Mahler S, Levy P, Parikh S, Krupp S, Nour K, Klausner H, Gindi R, Lewandowski A, Hudson M, Perrotta G, Zweig B, Lanfear D, Kim H, Dangoulian S, Tang A, Todter E, Khan A, Keerie C, Bole S, Nasseredine H, Oudeif A, Abou Asala E, Mohammed M, Kazem A, Malette K, Singh-Kucukarslan G, Xu N, Wittenberg S, Morton T, Gunaga S, Affas Z, Tabbaa K, Desai P, Alsaadi A, Mahmood S, Schock A, Konowitz N, Fuchs J, Joyce K, Shamoun L, Babel J, Broome A, Digiacinto G, Shaheen E, Darnell G, Muller G, Heath G, Bills G, Vieder J, Rockoff S, Kim B, Colucci A, Plemmons E, McCord J. Rapid Acute Coronary Syndrome Evaluation Over One Hour With High-Sensitivity Cardiac Troponin I: A United States-Based Stepped-Wedge, Randomized Trial. Ann Emerg Med 2024:S0196-0644(24)00235-X. [PMID: 38888531 DOI: 10.1016/j.annemergmed.2024.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 04/17/2024] [Accepted: 04/19/2024] [Indexed: 06/20/2024]
Abstract
STUDY OBJECTIVE The real-world effectiveness and safety of a 0/1-hour accelerated protocol using high-sensitivity cardiac troponin (hs-cTn) to exclude myocardial infarction (MI) compared to routine care in the United States is uncertain. The objective was to compare a 0/1-hour accelerated protocol for evaluation of MI to a 0/3-hour standard care protocol. METHODS The RACE-IT trial was a stepped-wedge, randomized trial across 9 emergency departments (EDs) that enrolled 32,609 patients evaluated for possible MI from July 2020 through April 2021. Patients undergoing high-sensitivity cardiac troponin I testing with concentrations less than or equal to 99th percentile were included. Patients who had MI excluded by the 0/1-hour protocol could be discharged from the ED. Patients in the standard care protocol had 0- and 3-hour troponin testing and application of a modified HEART score to be eligible for discharge. The primary endpoint was the proportion of patients discharged from the ED without 30-day death or MI. RESULTS There were 13,505 and 19,104 patients evaluated in the standard care and accelerated protocol groups, respectively, of whom 19,152 (58.7%) were discharged directly from the ED. There was no significant difference in safe discharges between standard care and the accelerated protocol (59.5% vs 57.8%; adjusted odds ratio (aOR)=1.05, 95% confidence interval [CI] 0.95 to 1.16). At 30 days, there were 90 deaths or MIs with 38 (0.4%) in the standard care group and 52 (0.4%) in the accelerated protocol group (aOR=0.84, 95% CI 0.43 to 1.68). CONCLUSION A 0/1-hour accelerated protocol using high-sensitivity cardiac troponin I did not lead to more safe ED discharges compared with standard care.
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Affiliation(s)
| | | | - Chaun Gandolfo
- Heart and Vascular Institute Henry Ford Health, Detroit, MI
| | | | - Simon Mahler
- Wake Forest University School of Medicine Winston-Salem, NC
| | - Phillip Levy
- Wayne State University School of Medicine, Detroit, MI
| | - Sachin Parikh
- Heart and Vascular Institute Henry Ford Health, Detroit, MI
| | | | - Khaled Nour
- Heart and Vascular Institute Henry Ford Health, Detroit, MI
| | | | - Ryan Gindi
- Heart and Vascular Institute Henry Ford Health, Detroit, MI
| | | | - Michael Hudson
- Heart and Vascular Institute Henry Ford Health, Detroit, MI
| | | | - Bryan Zweig
- Heart and Vascular Institute Henry Ford Health, Detroit, MI
| | - David Lanfear
- Heart and Vascular Institute Henry Ford Health, Detroit, MI
| | - Henry Kim
- Heart and Vascular Institute Henry Ford Health, Detroit, MI
| | | | - Amy Tang
- Henry Ford Hospital, Detroit, MI
| | | | | | | | | | | | | | | | | | | | | | | | - Nicole Xu
- Wayne State University School of Medicine, Detroit, MI
| | | | | | | | - Ziad Affas
- Henry Ford Macomb Hospital, Clinton Township, MI
| | | | - Parth Desai
- Wayne State University School of Medicine, Detroit, MI
| | | | | | | | | | | | | | - Lance Shamoun
- Wake Forest University School of Medicine Winston-Salem, NC
| | - Jacob Babel
- The Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Andrew Broome
- Wake Forest University School of Medicine Winston-Salem, NC
| | | | | | | | | | | | - Gust Bills
- Henry Ford West Bloomfield Hospital, West Bloomfield, MI, USA
| | | | - Steven Rockoff
- Henry Ford West Bloomfield Hospital, West Bloomfield, MI, USA
| | - Brian Kim
- Henry Ford Allegiance Hospital, Jackson, MI
| | | | | | - James McCord
- Heart and Vascular Institute Henry Ford Health, Detroit, MI.
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Mahler SA, Ashburn NP, Paradee BE, Stopyra JP, O'Neill JC, Snavely AC. Safety and Effectiveness of the High-Sensitivity Cardiac Troponin HEART Pathway in Patients With Possible Acute Coronary Syndrome. Circ Cardiovasc Qual Outcomes 2024; 17:e010270. [PMID: 38328912 DOI: 10.1161/circoutcomes.123.010270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 12/14/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND The HEART Pathway (History, Electrocardiogram, Age, Risk factors, Troponin) can be used with high-sensitivity cardiac troponin to risk stratify emergency department patients with possible acute coronary syndrome. However, data on whether a high-sensitivity HEART Pathway (hs-HP) are safe and effective is lacking. METHODS An interrupted time series study was conducted at 5 North Carolina sites in 26 126 adult emergency department patients being investigated for possible acute coronary syndrome and without ST-segment-elevation myocardial infarction. Patients were accrued into 16-month preimplementation and postimplementation cohorts with a 6-month wash-in phase. Preimplementation (January 2019 to April 2020), the traditional HEART Pathway was used with 0- and 3-hour contemporary troponin measures (Siemens). In the postimplementation period (November 2020 to February 2022), a modified hs-HP was used with 0- and 2-hour high-sensitivity cardiac troponin (Beckman Coulter) measures. The primary safety and effectiveness outcomes were 30-day all-cause death or myocardial infarction and 30-day hospitalizations. These outcomes and early discharge rate (emergency department discharge without stress testing or coronary angiography) were determined from health records and death index data. Outcomes were compared preimplementation versus postimplementation using χ2 tests and multivariable logistic regression to adjust for potential confounders. RESULTS Preimplementation and postimplementation cohorts included 12 317 and 13 809 patients, respectively, of them 52.7% (13 767/26 126) were female with a median age of 54 years (interquartile range, 42-66). Rates of 30-day death or MI were 6.8% (945/13 809) postimplementation and 7.7% (948/12 317) preimplementation (adjusted odds ratio, 1.00 [95% CI, 0.90-1.11]). hs-HP implementation was associated with 19.9% (95% CI, 18.7%-21.1%) higher early discharges (post versus pre: 63.6% versus 43.7%; adjusted odds ratio, 2.22 [95% CI, 2.10-2.35]). The hs-HP was also associated with 16.1% (95% CI, 14.9%-17.3%) lower 30-day hospitalizations (postimplementation versus preimplementation, 31.4% versus 47.5%; adjusted odds ratio, 0.51 [95% CI, 0.48-0.54]). Among early discharge patients, death or myocardial infarction occurred in 0.5% (41/8780) postimplementation versus 0.4% (22/5383) preimplementation (P=0.61). CONCLUSIONS hs-HP implementation is associated with increased early discharges without increasing adverse events. These findings support the use of a modified hs-HP to improve chest pain care.
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Affiliation(s)
- Simon A Mahler
- Department of Emergency Medicine (S.A.M., N.P.A., B.E.P., J.P.S., J.C.O., A.C.S.), Wake Forest University School of Medicine, Winston-Salem, NC
- Department of Implementation Science (S.A.M.), Wake Forest University School of Medicine, Winston-Salem, NC
- Department of Epidemiology and Prevention (S.A.M.), Wake Forest University School of Medicine, Winston-Salem, NC
| | - Nicklaus P Ashburn
- Department of Emergency Medicine (S.A.M., N.P.A., B.E.P., J.P.S., J.C.O., A.C.S.), Wake Forest University School of Medicine, Winston-Salem, NC
- Section on Cardiovascular Medicine, Department of Internal Medicine (N.P.A.), Wake Forest University School of Medicine, Winston-Salem, NC
| | - Brennan E Paradee
- Department of Emergency Medicine (S.A.M., N.P.A., B.E.P., J.P.S., J.C.O., A.C.S.), Wake Forest University School of Medicine, Winston-Salem, NC
| | - Jason P Stopyra
- Department of Emergency Medicine (S.A.M., N.P.A., B.E.P., J.P.S., J.C.O., A.C.S.), Wake Forest University School of Medicine, Winston-Salem, NC
| | - James C O'Neill
- Department of Emergency Medicine (S.A.M., N.P.A., B.E.P., J.P.S., J.C.O., A.C.S.), Wake Forest University School of Medicine, Winston-Salem, NC
| | - Anna C Snavely
- Department of Emergency Medicine (S.A.M., N.P.A., B.E.P., J.P.S., J.C.O., A.C.S.), Wake Forest University School of Medicine, Winston-Salem, NC
- Department of Biostatistics and Data Science (A.C.S.), Wake Forest University School of Medicine, Winston-Salem, NC
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Fiore G, Pinto G, Preda A, Rampa L, Gaspardone C, Oppizzi M, Slavich M, Di Napoli D, Bianchi G, Etteri M, Margonato A, Fragasso G. Performances of HEART score to predict 6-month prognostic of emergency department patients with chest pain: a retrospective cohort analysis. Eur J Emerg Med 2023; 30:179-185. [PMID: 37040660 DOI: 10.1097/mej.0000000000001022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
Chest pain is a frequent cause of patient admissions in emergency departments (EDs). Clinical scores can help in the management of chest pain patients with an undefined impact on the appropriateness of hospitalization or discharge when compared to usual care. The aim of this study was to assess the performances of the HEART score to predict the 6-month prognostic of patients presenting to the ED of a tertiary referral university hospital with non-traumatic chest pain. From 7040 patients presenting with chest pain from 1 January 2015 to 31 December 2017, after applying exclusion criteria (ST-segment elevation >1 mm, shock, absence of telephone number) we selected a sample of 20% chosen randomly. We retrospectively assessed the clinical course, definitive diagnosis, and HEART score according to ED final report. Follow-up was made by telephone interview with discharged patients. In hospitalized patients, clinical records were analyzed to evaluate major adverse cardiac events (MACE) incidence. The primary endpoint was MACE, comprising cardiovascular death, myocardial infarction, or unscheduled revascularization at 6 months. We assessed the diagnostic performance of the HEART score in ruling out MACE at 6 months. We also assessed the performance of ED usual care in the management of chest pain patients. Of 1119 screened, 1099 were included for analysis after excluding patients lost to follow-up; 788 patients (71.70%) had been discharged and 311 (28.30%) were hospitalized. Incident MACE was 18.3% (n = 205). The HEART score was retrospectively calculated in 1047 patients showing increasing MACE incidence according to risk category (0.98% for low risk, 38.02% for intermediate risk, and 62.21% for high risk). Low-risk category allowed to safely exclude MACE at 6 months with a negative predictive value (NPV) of 99%. Usual care diagnostic performance showed 97.38% sensitivity, 98.24% specificity, 95.5% positive predictive value, and 99% NPV, with an overall accuracy of 98.00%. In ED patients with chest pain, a low HEART score is associated with a very low risk of MACE at 6 months.
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Affiliation(s)
- Giorgio Fiore
- Department of Clinical Cardiology, University Hospital San Raffaele, Milano, Italy
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Snavely AC, Paradee BE, Ashburn NP, Allen BR, Christenson R, O'Neill JC, Nowak R, Wilkerson RG, Mumma BE, Madsen T, Stopyra JP, Mahler SA. Derivation and validation of a high sensitivity troponin-T HEART pathway. Am Heart J 2023; 256:148-157. [PMID: 36400184 DOI: 10.1016/j.ahj.2022.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The HEART Pathway is widely used for chest pain risk stratification but has yet to be optimized for high sensitivity troponin T (hs-cTnT) assays. METHODS We conducted a secondary analysis of STOP-CP, a prospective cohort study enrolling adult ED patients with symptoms suggestive of acute coronary syndrome at 8 sites in the United States (US). Patients had a 0- and 1-hour hs-cTnT measured and a HEAR score completed. A derivation set consisting of 729 randomly selected participants was used to derive a hs-cTnT HEART Pathway with rule-out, observation, and rule-in groups for 30-day cardiac death or myocardial infarction (MI). Optimal baseline and 1-hour troponin cutoffs were selected using generalized cross validation to achieve a negative predictive value (NPV) >99% for rule out and positive predictive value (PPV) >60% or maximum Youden index for rule-in. Optimal 0-1-hour delta values were derived using generalized cross validation to maximize the NPV for the rule-out group and PPV for the rule-in group. The hs-cTnT HEART Pathway performance was validated in the remaining cohort (n = 723). RESULTS Among the 1452 patients, 30-day cardiac death or MI occurred in 12.7% (184/1452). Within the derivation cohort the optimal hs-cTnT HEART Pathway classified 36.5% (266/729) into the rule-out group, yielding a NPV of 99.2% (95% CI: 98.2-100) for 30-day cardiac death or MI. The rule-in group included 15.4% (112/729) with a PPV of 55.4% (95% CI: 46.2-64.6). In the validation cohort, the hs-cTnT HEART Pathway ruled-out 37.6% (272/723), of which 2 had 30-day cardiac death or MI, yielding a NPV of 99.3% (95% CI: 98.3-100). The rule-in group included 14.5% (105/723), yielding a PPV of 57.1% (95% CI: 47.7-66.6). CONCLUSIONS A novel hs-cTnT HEART Pathway with serial 0- and 1-hour hs-cTnT measures has high NPV and moderate PPV for 30-day cardiac death or MI.
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Affiliation(s)
- Anna C Snavely
- Department of Biostatistics and Data Science, Wake Forest School of Medicine (WFSOM), Winston-Salem, NC; Department of Emergency Medicine, WFSOM, Winston Salem, NC.
| | | | | | - Brandon R Allen
- Department of Emergency Medicine, College of Medicine, University of Florida, Gainesville, FL
| | - Robert Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD
| | | | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Health, Detroit, MI
| | - R Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Bryn E Mumma
- Department of Emergency Medicine, School of Medicine, University of California Davis, Sacramento, CA
| | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | | | - Simon A Mahler
- Department of Emergency Medicine, WFSOM, Winston Salem, NC; Department of Implementation Science, WFSOM, Winston-Salem, NC; Department of Epidemiology and Prevention, WFSOM, Winston-Salem, NC
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Aarts GW, Camaro C, Vermaas N, Kamps J, van Herwaarden AE, Cramer GE, van Kimmenade RR, van Royen N, van Geuns R, Damman P. Implementation of the ESC 0 h/1h algorithm and the HEART score in the emergency department: A prospective cohort study. IJC HEART & VASCULATURE 2022; 39:100988. [PMID: 35257026 PMCID: PMC8897680 DOI: 10.1016/j.ijcha.2022.100988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/21/2022] [Accepted: 02/27/2022] [Indexed: 11/25/2022]
Abstract
Background The European Society of Cardiology (ESC) 0 h/1h algorithm is the preferred diagnostic strategy for chest pain patients in the emergency department (ED). It is suggested that adding clinical information to the algorithm improves its diagnostic performance. This study evaluates implementation of the ESC 0 h/1h algorithm in the ED and investigates the potential advantages of combining it with a clinical decision rule, which might be especially relevant in the heterogenous observation category. Methods In this prospective cohort study, chest pain patients in whom the ESC 0 h/1h algorithm was applied were enrolled. HEART score components were collected. Diagnostic characteristics were determined for the algorithm with and without addition of the HEART score. Primary endpoint was a composite endpoint at 30-day follow-up, consisting of myocardial infarction and death. Results A total of 668 patients were enrolled. The rule-in and rule-out categories consisted of 8.2% and 54.9% of the patients, respectively. Positive predictive value and specificity of the rule-in category were 67.3% and 97.1%, respectively. Negative predictive value (NPV) and sensitivity of the rule-out category were both 100%. In the observation category, a HEART score ≤ 3 yielded a NPV and sensitivity of 97.1% and 93.8%, respectively. Conclusion The ESC 0 h/1h algorithm yielded a NPV and sensitivity of 100% for myocardial infarction and death at 30-day follow-up. Addition of the HEART score did not provide clinically relevant advantages. Although the HEART score can be used to guide diagnostic testing in the observation category, a low HEART score did not yield an NPV of > 99%.
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Galea N, Bellu R, Catapano F, Marchitelli L, Cannavale G, Sedati P, Colmo C, Zamana A, Arboit M, Raspanti X, Roncacci A, Catalano C, Francone M. Coronary Computed Tomography Angiography in acute chest pain: a sustainable model with remote support. Eur J Radiol 2022; 151:110277. [DOI: 10.1016/j.ejrad.2022.110277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 02/20/2022] [Accepted: 03/20/2022] [Indexed: 11/30/2022]
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Ma C, Liu X, Ma L. A New Risk Score for Patients With Acute Chest Pain and Normal High Sensitivity Troponin. Front Med (Lausanne) 2022; 8:728339. [PMID: 35059410 PMCID: PMC8764281 DOI: 10.3389/fmed.2021.728339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 10/28/2021] [Indexed: 11/25/2022] Open
Abstract
Objective: To investigate a new risk score for patients who suffered from acute chest pain with normal high-sensitivity troponin I (hs-TnI) levels. Methods: In this study, patients with acute chest pain who were admitted to the emergency department (ED) of our hospital had been recruited. Hs-TnI was measured in serum samples drawn on admission to the ED. The end point was the occurrence of major adverse cardiac events (MACE) within 3 months. Predictor variables were selected by logistic regression analysis, and external validity was assessed in this study. Furthermore, validation was performed in an independent cohort, i.e., 352 patients (validation cohort). Results: A total of 724 patients were included in the derivation cohort. The results showed that four predictor variables were significant in the regression analysis—male, a history of chest pain, 60 years of age or older and with three or more coronary artery disease (CAD) risk factors. A total of 105 patients in the validation cohort had serious adverse cardiac events. The validation cohort showed a homogenous pattern with the derivation cohort when patients were stratified by score. The area under the curve (AUC) of the receiver operating characteristic (ROC) in the derivation cohort was 0.80 (95% CI: 0.76–0.83), while in the validation cohort, it was 0.79 (95% CI: 0.75–0.82). Conclusion: A new risk score was developed for acute chest pain patients without known CAD and ST-segment deviation and with normal hs-TnI and may aid MACE risk assessment and patient triage in the ED.
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Affiliation(s)
- Chunpeng Ma
- Department of Cardiology, The First Hospital of Qinhuangdao, Qinhuangdao, China
| | - Xiaoli Liu
- Department of Endocrinology, The First Hospital of Qinhuangdao, Qinhuangdao, China
| | - Lixiang Ma
- Department of Cardiology, The First Hospital of Qinhuangdao, Qinhuangdao, China
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Ma CP, Liu XL, Feng JS, Dong XF. Development and validation of a risk score for chest pain with suspected non-ST-segment elevation acute coronary syndrome. Ann Noninvasive Electrocardiol 2021; 27:e12929. [PMID: 34964535 PMCID: PMC9107085 DOI: 10.1111/anec.12929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/13/2021] [Indexed: 12/01/2022] Open
Abstract
Objective To investigate a new risk score for acute chest pain with suspected non‐ST‐segment elevation acute coronary syndrome (NSTE‐ACS). Methods Patients who suffered from Chest pain and suspected NSTE‐ACS were enrolled as subjects. Predictor variables had been analyzed, and a bootstrap technique was used to evaluate the internal validity of the model, and external validation had been assessed for a prospective cohort study. Results Thousand five hundred and sixty‐eight patients had been included in this study. Six predictor variables were found to be significant and were used to develop the model. The C‐statistic of the model was 0.83, and internal validation revealed the stability of the model and the absence of over‐optimism. Patients were given different triage recommendations, and the risk score was prospectively validated. Conclusions A risk score may be a suitable method for assessing the risk of major adverse cardiac events and aiding patient triage in emergency departments among patients with suspected NSTE‐ACS.
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Affiliation(s)
- Chun-Peng Ma
- Department of Cardiology, The First Hospital of Qinhuangdao, Hebei Province, China
| | - Xiao-Li Liu
- Department of Endocrinology, The First Hospital of Qinhuangdao, Hebei Province, China
| | - Jian-Shuang Feng
- Department of Cardiology, The First Hospital of Qinhuangdao, Hebei Province, China
| | - Xue-Fei Dong
- Department of Cardiology, The First Hospital of Qinhuangdao, Hebei Province, China
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Rocha B, Aguiar C. NSTE-ACS at the Emergency: Can You Guess What is Under the Umbrella? Arq Bras Cardiol 2021; 117:288-289. [PMID: 34495220 PMCID: PMC8395799 DOI: 10.36660/abc.20210516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Bruno Rocha
- Centro Hospitalar Lisboa OcidentalHospital de Santa CruzDepartamento de CardiologiaLisboaPortugalDepartamento de Cardiologia, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisboa - Portugal
- Centro Hospitalar Lisboa OcidentalHospital de Santa CruzUnidade de Insuficiência Cardíaca Avançada e Transplante CardíacoLisboaPortugalUnidade de Insuficiência Cardíaca Avançada e Transplante Cardíaco, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisboa - Portugal
| | - Carlos Aguiar
- Centro Hospitalar Lisboa OcidentalHospital de Santa CruzDepartamento de CardiologiaLisboaPortugalDepartamento de Cardiologia, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisboa - Portugal
- Centro Hospitalar Lisboa OcidentalHospital de Santa CruzUnidade de Insuficiência Cardíaca Avançada e Transplante CardíacoLisboaPortugalUnidade de Insuficiência Cardíaca Avançada e Transplante Cardíaco, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisboa - Portugal
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Khan E, Lambrakis K, Blyth A, Seshadri A, Edmonds MJR, Briffa T, Cullen LA, Quinn S, Horsfall M, Morton E, French JK, Papendick C, Nelson AJ, Chew DP. Classification performance of clinical risk scoring in suspected acute coronary syndrome beyond a rule-out troponin profile. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:1038-1047. [PMID: 34195809 DOI: 10.1093/ehjacc/zuab040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/19/2021] [Accepted: 05/22/2021] [Indexed: 11/15/2022]
Abstract
AIMS High-sensitivity cardiac troponin strategies can provide risk stratification in patients with suspected acute coronary syndrome (ACS) in the emergency department (ED). This study evaluated whether clinical risk scoring improves the classification performance of a rule-out profile in suspected ACS. METHODS AND RESULTS Patients presenting to ED with suspected ACS as part of the RAPID-TnT trial randomized to the intervention arm were included. Results ≥5 ng/L were available for all participants in this analysis. We evaluated the Thrombolysis In Myocardial Infarction (TIMI) risk score, History ECG Age Risk factors Troponin (HEART) score, and Emergency Department Assessment of Chest pain Score (EDACS) in addition to a rule-out profile based on the 0/1-h high-sensitivity cardiac troponin T protocol (<5 ng/L or ≤12 ng/L and a change of <3 ng/L at 1-h) using test performance parameters focusing on low-risk groups to identify the primary endpoint (TIMI ≤ 1, HEART ≤ 3, EDACS < 16). Primary endpoint was a composite of type 1/2 myocardial infarction (MI) at index presentation and all-cause mortality or type 1/2 MI at 30 days. A total of 3378 participants were enrolled between August 2015 and April 2019 of which 108 were ineligible/withdrew consent (intervention arm: n = 1638). Sensitivity, specificity, negative predictive value (NPV), and area under the curve (AUC) of the rule-out profile was 94.4%, 76.8%, 99.6%, and 0.86, respectively with 72.9% identified as 'low-risk'. Adding the clinical risk scores did not improve the sensitivity, NPV, or AUC with significantly lower specificity and 'low-risk' classified participants. CONCLUSIONS Addition of clinical risk scores to rule-out profile did not demonstrate improved classification performance for identifying the composite of type 1/2 MI at index presentation and all-cause mortality or type 1/2 MI at 30 days. CLINICAL TRIALS REGISTRATION URL: https://www.anzctr.org.au. Reg. No. ACTRN12615001379505.
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Affiliation(s)
- Ehsan Khan
- College of Medicine & Public Health, Flinders University, Sturt Road, Bedford Park, SA 5042, Australia
- South Australian Department of Health, 11 Hindmarsh Square, Adelaide, SA 5000, Australia
| | - Kristina Lambrakis
- College of Medicine & Public Health, Flinders University, Sturt Road, Bedford Park, SA 5042, Australia
- South Australian Department of Health, 11 Hindmarsh Square, Adelaide, SA 5000, Australia
| | - Andrew Blyth
- College of Medicine & Public Health, Flinders University, Sturt Road, Bedford Park, SA 5042, Australia
- South Australian Department of Health, 11 Hindmarsh Square, Adelaide, SA 5000, Australia
| | - Anil Seshadri
- College of Medicine & Public Health, Flinders University, Sturt Road, Bedford Park, SA 5042, Australia
- South Australian Department of Health, 11 Hindmarsh Square, Adelaide, SA 5000, Australia
| | - Michael J R Edmonds
- South Australian Department of Health, 11 Hindmarsh Square, Adelaide, SA 5000, Australia
| | - Tom Briffa
- School of Population and Global Health, University of Western Australia, Clifton Street, Nedlands, Perth, WA 6009, Australia
| | - Louise A Cullen
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD 4029, Australia
- School of Public Health, Queensland University of Technology, George Street, Brisbane, QLD 4000, Australia
- School of Medicine, University of Queensland, St Lucia, Brisbane, QLD 4072, Australia
| | - Stephen Quinn
- Department of Statistics, Swinburne University of Technology, John Street, Hawthorne, Melbourne, VIC 3122, Australia
- Department of Health Science and Biostatistics, Swinburne University of Technology, John Street, Hawthorne, Melbourne, VIC 3122, Australia
| | - Matthew Horsfall
- College of Medicine & Public Health, Flinders University, Sturt Road, Bedford Park, SA 5042, Australia
- South Australian Department of Health, 11 Hindmarsh Square, Adelaide, SA 5000, Australia
| | - Erin Morton
- College of Medicine & Public Health, Flinders University, Sturt Road, Bedford Park, SA 5042, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, Elizabeth & Goulburn Street, Liverpool, Sydney, NSW 2170, Australia
| | - Cynthia Papendick
- School of Population and Global Health, University of Western Australia, Clifton Street, Nedlands, Perth, WA 6009, Australia
| | - Adam J Nelson
- South Australian Department of Health, 11 Hindmarsh Square, Adelaide, SA 5000, Australia
- South Australian Health and Medical Research Institute, North Terrace, Adelaide, SA 5000, Australia
- School of Medicine, University of Adelaide, North Terrrace, Adelaide, SA 5000, Australia
| | - Derek P Chew
- College of Medicine & Public Health, Flinders University, Sturt Road, Bedford Park, SA 5042, Australia
- South Australian Department of Health, 11 Hindmarsh Square, Adelaide, SA 5000, Australia
- School of Population and Global Health, University of Western Australia, Clifton Street, Nedlands, Perth, WA 6009, Australia
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Vrints CJ. Update on the emergency department diagnosis and risk stratification of acute chest pain. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2020; 9:3-4. [PMID: 32031429 DOI: 10.1177/2048872620906939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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