P2712Integration of new CENTAUR high-sensitivity Troponin I assay with HEART score chest pain pathway to maximise early discharge from emergency department

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
E M Thet ◽  
J J Murphy ◽  
J G Crilley
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Troponin I ◽  
High Sensitivity ◽  
Early Discharge ◽  
Low Risk ◽  
Acute Pulmonary Oedema ◽  
Original Cohort ◽  
Heart Score ◽  
Coronary Syndrome

Abstract Introduction Chest pain is a common presentation to the emergency department (ED). Differentiating those with an Acute Coronary Syndrome from the majority without, within 4 hours, is a priority. Introduction of high-sensitivity TnI assays has the potential to allow early discharge from ED but at the expense of lower specificity. Given the pressure in ED to identify patients who can safely be discharged we developed an algorithm based on the HEART score. This combines the history, ECG, age, risk factors and hsTnI level and outperforms TIMI and GRACE scores in identifying low-risk patients. Patients with a score of ≥4 have an increased major adverse cardiac event (MACE) rate at 30 days; those with a score of <4 are suitable for early discharge. There are no studies utilising the CENTAUR assay combined with a clinical risk score. Methods An initial algorithm based on the HEART score tool was developed incorporating estimated hsTnI boundaries for the CENTAUR assay to inform the “T” component of the tool. This was tested on a 2 month sample of patients presenting with chest pain to the ED. Following review a revised pathway was developed. Patient outcome was recorded with both pathways including subsequent investigations and MACE at 30 days and compared with historical discharge rates for chest pain from the same ED. Sensitivity, specificity and NPV were calculated. Results There were 478 presentations with chest pain and at least one hsTnI level. Age ranged from 13 to 98 years (median 56); 50% were male. There were 21 (4%) MACE within 30 days of the initial presentation (NSTEMI: 18, STEMI: 1, unstable angina requiring CABG: 1, acute pulmonary oedema: 1). A 2 hour hsTnI ≤8 identified a low-risk group with no MACE <30 days. 30% of patients using the initial pathway had a HEART score of ≥4 (100% sens, 73% spec). 70% were suitable for ED discharge; there were no MACE in this group (100% NPV). A revised pathway was derived incorporating previous cardiac history and modified hsTnI boundaries. Applying this to the original cohort would have increased the proportion suitable for ED discharge to 82%. Both pathways improved the proportion of patients who could be discharged directly from ED from a historical 64%. The revised pathway demonstrated improved specificity for the identification of MACE with no loss of sensitivity and excellent negative predictive value. (100% sens, 86% spec, 100% NPV). Conclusions The CENTAUR hs-TnI assay and HEART score with modifications would facilitate the early discharge of patients with chest pain from ED within 4 hours without missing any MACE at 30 days. This conclusion should be validated in a prospective cohort.

Risk stratifying chest pain patients in the emergency department using HEART, GRACE and TIMI scores, with a single contemporary troponin result, to predict major adverse cardiac events

2018 ◽  
Vol 35 (7) ◽  
pp. 420-427 ◽  
Author(s):  
Peter D W Reaney ◽  
Hamish I Elliott ◽  
Awsan Noman ◽  
Jamie G Cooper
Keyword(s):  
Chest Pain ◽  
High Sensitivity ◽  
Tertiary Hospital ◽  
Low Risk ◽  
Cardiac Events ◽  
Heart Score ◽  
Coronary Syndrome ◽  
C Statistic ◽  
Diagnostic Characteristics ◽  
Coronary Events

BackgroundThe majority of patients presenting to the ED with cardiac sounding chest pain have a non-diagnostic ECG and the problem of differentiating those suffering an acute coronary syndrome from those without is familiar to all ED clinical staff. To stratify risk in these patients, specific scores have been developed. Recent work has focused on incorporating newer high-sensitivity cardiac troponin (hs-cTn) assays; however, issues regarding performance and availability of these assays remain.AimProspectively compare HEART, Global Registry of Acute Coronary Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) scores, using a single contemporary cTn at admission, to predict a major adverse cardiac event (MACE) at 30 days.MethodProspective observational cohort study performed in a UK tertiary hospital in patients with suspected cardiac chest pain and no significant ST elevation on initial ECG. Data collection took place 2 December 2014 to 8 February 2016. The treating clinician recorded risk score data real time and a single contemporary cTn taken at presentation was used in score calculation. The primary endpoint was 30-day MACE. C-statistic was determined for each score and diagnostic characteristics of high-risk and low-risk cut-offs were calculated.Results189/1000 patients in the study developed a 30-day MACE. The c-statistic of HEART for 30-day MACE (0.87 (95% CI 0.84 to 0.90)) was higher than TIMI (0.78 (95% CI 0.74 to 0.81)) and GRACE (0.74 (95% CI 0.70 to 0.78)).HEART score ≤3 identified low-risk patients with sensitivity 99.5% (95% CI 97.1% to 99.9%) and negative predictive value (NPV) 99.6% (95% CI 97.3% to 99.9%) exceeding TIMI 0 (sensitivity 97.4% (95% CI 93.9% to 99.1%) and NPV 97.8% (95% CI 94.8% to 99.1%)) and GRACE score 0–55 (sensitivity 95.2% (95% CI 91.1% to 97.8%) and NPV 95.8% (95% CI 92.2% to 97.7%)).ConclusionHEART outperformed both TIMI and GRACE in overall discriminative capacity for 30-day MACE. Using a single contemporary cTn at presentation, a HEART score of ≤3 demonstrated sensitivity and NPV of ≥99.5% for 30-day MACE. These results reach the threshold for a safe discharge strategy but should be interpreted thoughtfully in light of other work.

scholarly journals LO97: Validation of the HEART score in Canadian emergency department chest pain patients using a high-sensitivity troponin T assay

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S61-S62 ◽  
Author(s):  
J. Andruchow ◽  
A. McRae ◽  
T. Abedin ◽  
D. Wang ◽  
G. Innes ◽  
...  
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Troponin T ◽  
High Sensitivity ◽  
Low Risk ◽  
Moderate Risk ◽  
Heart Score ◽  
High Sensitivity Troponin ◽  
High Sensitivity Troponin T ◽  
Pain Patients

Introduction: The HEART score is a validated tool created to risk stratify emergency department (ED) chest pain patients using 5 simple criteria (History, ECG findings, Age, Risk factors, and Troponin). Several studies have demonstrated the superiority of HEART over other well known risk stratification tools in identifying low risk chest pain patients suitable for early discharge. All but one of these studies used conventional troponin assays, and most were conducted in European populations. This study aims to validate the HEART score using a high-sensitivity troponin T assay in a Canadian population. Methods: This prospective cohort study was conducted at a single urban tertiary centre and regional percutaneous coronary intervention site in Calgary, Alberta. Patients were eligible for enrolment if they presented to the ED with chest pain, were age 25-years or older and required biomarker testing to rule out AMI at the discretion of the attending emergency physician. Patients were excluded if they had clear acute ischemic ECG changes, new arrhythmia or renal failure requiring hemodialysis. Clinical data were recorded by the emergency physician at the time of enrolment and outcomes were obtained from administrative data. High-sensitivity troponin-T (Roche Elecsys hs-cTnT) results were obtained in all patients at presentation. The primary outcome was AMI within 30-days of ED visit, the secondary outcome was 30-day major adverse cardiac events (MACE). Results: A total of 984 ED patients with complete HEART scores were enrolled from August 2014 to September 2016. The 30-day incidence of AMI and MACE in the overall population was 3.3% and 20.6%, respectively. HEART scores were predictive of 30-day AMI incidence: low risk (0-3): 0.77% (95%CI 0.0-1.5%), moderate risk (4-6): 4.3% (95%CI 2.3-6.2%) and high risk (7-10): 12.2% (95%CI 5.5-19.0%). HEART scores also predicted 30-day MACE: low risk (0-3): 5.0% (95%CI 3.1-6.9%), moderate risk (4-6): 31.8% (95%CI 27.2-36.4%) and high-risk (7-10): 61.4% (95%CI 51.2-71.5%). More than half of patients, 522 (53.0%) could be identified as low risk based on the HEART score using a single troponin result. Conclusion: Using a single high-sensitivity troponin result collected at ED presentation, the HEART score can rapidly and effectively identify more than half of ED chest pain patients as low risk for 30-day AMI, but is less sensitive for 30-day MACE.

scholarly journals Performance Of The Modified Heart Score In An Asian Population

2020 ◽  
Author(s):  
Shanaz Sajeed ◽  
Michael De Dios ◽  
Dan Ong Wei Jun ◽  
Amila Clarence Punyadasa
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Risk Stratification ◽  
Risk Group ◽  
Asian Population ◽  
Low Risk ◽  
Predictive Tool ◽  
Heart Score ◽  
Coronary Syndrome ◽  
Chinese Study

Abstract INTRODUCTION Chest pain is the most common potentially life threatening presentation to the emergency department (ED). Furthermore, the identification of acute coronary syndrome (ACS) including its risk stratification and subsequent disposition can be challenging. The original HEART score was derived as a predictive tool to risk stratify patients presenting with undifferentiated chest pain (CP) and aid physician decision-making. However, it utilized conventional Troponins as its cardiac biomarker component. Our study aims to assess the utility of the modified HEART score with highly sensitive troponins in an Asian setting with mixed ethnicity to determine if it corroborates the findings of the another recent Chinese study by Chun-Peng MA et al[7]. METHODS Clinical data from 413 patients presenting to the ED for evaluation of chest pain were analyzed. The predictive value of the modified HEART score for determining MACE was then evaluated.RESULTS 49 patients (11.9%) had a MACE: 31 patients (7.5%) underwent PCI, and 1 patient (0.2%) underwent CABG. There were 17 (4.1%) deaths.Three risk groups were elucidated based on MACE. In the low risk group (0-2), there were 72 patients (17.4%), with a MACE rate of 1.4%. In the intermediate risk group (3-5), there were 233 patients (56.4%), with a MACE rate of 5.2%. In the high risk group (6-10), there were 108 patients (26.2%), with a MACE rate of 33.3%. CONCLUSION The modified HEART score is an effective risk stratification tool in an ethnically diverse Asian population. Furthermore, it identifies low risk patients who are candidates for early discharge from a local emergency department.

Single high-sensitivity troponin levels to assess patients with potential acute coronary syndromes

Heart ◽  
2021 ◽  
pp. heartjnl-2020-317997 ◽  
Author(s):  
Cara Barnes ◽  
Daniel M Fatovich ◽  
Stephen P J Macdonald ◽  
Richard F Alcock ◽  
Jon R Spiro ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Emergency Department ◽  
Cardiac Troponin ◽  
Troponin I ◽  
High Sensitivity ◽  
Early Discharge ◽  
Coronary Syndrome ◽  
Registration Number ◽  
Risk Patients

ObjectiveWe tested the hypothesis that patients with a potential acute coronary syndrome (ACS) and very low levels of high-sensitivity cardiac troponin I can be efficiently and safely discharged from the emergency department after a single troponin measurement.MethodsThis prospective cohort study recruited 2255 consecutive patients aged ≥18 years presenting to the Emergency Department, Royal Perth Hospital, Western Australia, with chest pain without high-risk features but requiring the exclusion of ACS. Patients were managed using a guideline-recommended pathway or our novel Single Troponin Accelerated Triage (STAT) pathway. The primary outcome was the percentage of patients discharged in <3 hours. Secondary outcomes included the duration of observation and death or acute myocardial infarction in the next 30 days.ResultsThe study enrolled 1131 patients to the standard cohort and 1124 to the STAT cohort. Thirty-eight per cent of the standard cohort were discharged directly from emergency department compared with 63% of the STAT cohort (p<0.001). The median duration of observation was 4.3 (IQR 3.3–7.1) hours in the standard cohort and 3.6 (2.6–5.4) hours in the STAT cohort (p<0.001), with 21% and 38% discharged in <3 hours, respectively (p<0.001). No patients discharged directly from the emergency department died or suffered an acute myocardial infarction within 30 days in either cohort.ConclusionsAmong low-risk patients with a potential ACS, a pathway which incorporates early discharge based on a single very low level of high-sensitivity cardiac troponin increases the proportion of patients discharged directly from the emergency department, reduces length of stay and is safe.Trial registration numberACTRN12618000797279.

Approach to the Patient Presenting with Chest Pain

2019 ◽  
Author(s):  
Elizabeth Temin
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
High Sensitivity ◽  
Emergency Department Patient ◽  
The United States ◽  
Benign Condition ◽  
Heart Score ◽  
Coronary Syndrome ◽  
Ct Angiogram ◽  
Important Challenge

Caring for the emergency department patient with chest pain represents an important challenge to the emergency physician. Chest pain is the second most common presentation among all emergency department patients, accounting for approximately 6 million visits per year in the United States. Chest pain may represent a benign condition or a time-critical life threat; symptom overlap between benign and serious conditions can make an accurate chest pain diagnosis challenging. This review covers the pathophysiology, assessment, stabilization, diagnosis and treatment, and disposition and outcomes of chest pain.  This review contains 1 figure, 25 tables, and 36 references. Key words: acute coronary syndrome, acute myocardial infarction,  angina pectoris, chest pain, coronary artery disease,  pulmonary embolism, high sensitivity troponin, HEART Score, EDAC score, cardiac CT Angiogram

Nurse-led chest pain hot clinics: improving patient flow in the emergency department

2020 ◽  
Vol 15 (5) ◽  
pp. 1-11
Author(s):  
Jon Taylor ◽  
Agnieszka Kopanska ◽  
Tessa Cobb
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Length Of Stay ◽  
Troponin I ◽  
Patient Flow ◽  
Low Risk ◽  
Heart Score ◽  
Ensure Patient Safety ◽  
Number Of Patients ◽  
Risk Patients

This article describes the authors' experiences of a specialist pathway for low-risk patients with chest pain admitted to the emergency department. This pathway uses a modified HEART score and highly sensitive troponin I testing to categorise patients. This was introduced to facilitate safe and speedy discharge of these patients within the 4-hour target. The aim was to demonstrate a reduction in length of stay and a reduction in overcrowding in the emergency department. This also included the introduction of a new nurse-led chest pain hot clinic to provide a specialist cardiology review within 72 hours of discharge. This clinic enabled more appropriate targeted investigation and treatment for patients. As a new initiative, it was important to ensure patient safety with a <1% incidence of major adverse cardiac event at 30 days, which was achieved. The modified HEART score also enabled more low-risk patients to be rapidly discharged from the emergency department. The chest pain hot clinics ensure patients are appropriately assessed and investigated for coronary artery disease reducing the number of unnecessary investigations. It also demonstrated a reduction in the number of computerised tomography coronary angiogram requests enabling more appropriate and timely investigations. In addition, there was a reduction in medical admissions and emergency department overcrowding. These initiatives also reduced the overall length of stay and increased the number of patients discharged within the 4-hour target from the emergency department.

scholarly journals Performance of The Modified Heart Score In An Asian Population

2020 ◽  
Author(s):  
Shanaz Sajeed ◽  
Michael De Dios ◽  
Dan Ong Wei Jun ◽  
Amila Clarence Punyadasa
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Risk Stratification ◽  
Risk Group ◽  
Asian Population ◽  
Low Risk ◽  
Predictive Tool ◽  
Heart Score ◽  
Coronary Syndrome ◽  
Chinese Study

Abstract INTRODUCTION Chest pain is the most common potentially life threatening presentation to the emergency department (ED). Furthermore, the identification of acute coronary syndrome (ACS) including its risk stratification and subsequent disposition can be challenging. The original HEART score was derived as a predictive tool to risk stratify patients presenting with undifferentiated chest pain (CP) and aid physician decision-making. However, it utilized conventional Troponins as its cardiac biomarker component. Our study aims to assess the utility of the modified HEART score with highly sensitive troponins in an Asian setting with mixed ethnicity to determine if it corroborates the findings of the another recent Chinese study by Chun-Peng MA et al[7]. METHODS Clinical data from 413 patients presenting to the ED for evaluation of chest pain were analyzed. The predictive value of the modified HEART score for determining MACE was then evaluated. RESULTS 49 patients (11.9%) had a MACE: 31 patients (7.5%) underwent PCI, and 1 patient (0.2%) underwent CABG. There were 17 (4.1%) deaths. Three risk groups were elucidated based on MACE. In the low risk group (0-2), there were 72 patients (17.4%), with a MACE rate of 1.4%. In the intermediate risk group (3-5), there were 233 patients (56.4%), with a MACE rate of 5.2%. In the high risk group (6-10), there were 108 patients (26.2%), with a MACE rate of 33.3%. CONCLUSION The modified HEART score is an effective risk stratification tool in an ethnically diverse Asian population. Furthermore, it identifies low risk patients who are candidates for early discharge from a local emergency department.

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