Diagnostic accuracy of the HEART Pathway and EDACS-ADP when combined with a 0-hour/1-hour hs-cTnT protocol for assessment of acute chest pain patients

Background/aimIn ED chest pain patients, a 0-hour/1-hour protocol based on high sensitivity cardiac troponin T (hs-cTnT) tests combined with clinical risk stratification in diagnosing acute coronary syndrome is recommended. Two of the most promising risk stratification tools are the History, ECG, Age, Risk Factors and Troponin (HEART) and Emergency Department Assessment of Chest Pain (EDAC) scores. Few studies have assessed the diagnostic accuracy of the 0-hour/1-hour hs-cTnT protocol when combined with HEART score, and none with EDACS. In ED chest pain patients, we aimed to evaluate the diagnostic accuracy of a 0-hour/1-hour hs-cTnT protocol combined the HEART Pathway, or the EDACS accelerated diagnostic pathway (EDACS-ADP).MethodsThis was a secondary analysis of data from a prospective observational study enrolling 1167 ED chest pain patients who visited the ED at Skåne University Hospital in Lund, Sweden in the period between February 2013 and April 2014. HEART and EDAC scores were assessed together with hs-cTnT at 0 and 1 hour and compared with HEART score alone. Sensitivity, specificity, negative predictive value (NPV) and likelihood ratios were evaluated. The primary outcome was major adverse cardiac events (MACE) including unstable angina within 30 days. The secondary outcome was index visit acute myocardial infarction (AMI).ResultsA total of 939 patients were included in the final analysis. When combined with 0-hour/1-hour hs-cTnT testing, the HEART Pathway and EDACS-ADP identified 49.8% and 49.6% of the patients for rule-out, with NPVs for 30-day MACE of 99.8% and 99.1%, compared with the HEART score alone that identified 53.4% of the patients for rule-out with NPV of 99.2%. The NPV for index visit AMI were 100%, 99.8% and 99.2%, respectively.ConclusionThe combination of the HEART Pathway or the EDACS-ADP with a 0-hour/1-hour hs-cTnT protocol allows safe and early rule-out in a large proportion of ED chest pain patients.

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Reliability of the CARE rule and the HEART score to rule out an acute coronary syndrome in non-traumatic chest pain patients

Internal and Emergency Medicine ◽

10.1007/s11739-018-1803-4 ◽

2018 ◽

Vol 13 (7) ◽

pp. 1111-1119 ◽

Cited By ~ 3

Author(s):

Thomas Moumneh ◽

Vanessa Richard-Jourjon ◽

Emilie Friou ◽

Fabrice Prunier ◽

Caroline Soulie-Chavignon ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Chest Pain ◽

Heart Score ◽

Coronary Syndrome ◽

Pain Patients ◽

Rule Out

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Effectiveness and Safety of the European Society of Cardiology 0-/1-h Troponin Rule-Out Protocol: The Design of the ESC-TROP Multicenter Implementation Study

Cardiology ◽

10.1159/000509390 ◽

2020 ◽

Vol 145 (11) ◽

pp. 685-692

Author(s):

Arash Mokhtari ◽

Ardavan Khoshnood ◽

Jakob Lundager Forberg ◽

Caroline Hård af Segerstad ◽

Ulf Ekström ◽

...

Keyword(s):

Chest Pain ◽

Clinical Assessment ◽

European Society ◽

Troponin T ◽

High Sensitivity ◽

Routine Care ◽

Coronary Syndrome ◽

European Society Of Cardiology ◽

Pain Patients ◽

Rule Out

Chest pain is one of the most common complaints at the emergency department (ED), and it is commonly the perceived likelihood of acute coronary syndrome (ACS) that drives management. Guidelines from the European Society of Cardiology (ESC) recommend the use of a 0-/1-h high-sensitivity cardiac troponin T (hs-cTnT) protocol to rule out or in ACS, but this is mostly based on observational studies. The aim of the ESC-TROP trial is to determine the safety and effectiveness of the ESC 0-/1-h hs-cTnT protocol when implemented in routine care. Adult chest pain patients at 5 EDs in the Skåne Region, Sweden, are included in the trial. The 0-/1-h hs-cTnT ESC protocol supplemented with clinical assessment and electrocardiography (ECG) is implemented at 3 EDs, and the other 2 EDs act as concurrent controls. Outcomes will be evaluated during the 10 months after the implementation and the corresponding 10 months of the previous year. The 2 co-primary outcomes are (a) acute myocardial infarction (AMI) and all-cause death within 30 days in patients discharged from the ED, and (b) ED length of stay of the same patients. Secondary outcomes include the proportion of chest pain patients discharged from the ED and the number of ruled-out patients undergoing objective testing within 30 days. The ESC-TROP trial will determine the performance and applicability of the 0-/1-h hs-cTnT ESC protocol supplemented with clinical assessment and ECG when implemented in routine ED care. It will provide evidence whether 0-/1-h hs-cTnT testing is safe, effective, and feasible, and whether widespread implementation as recommended by ESC guidelines should be supported.

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Combined Use of High-Sensitive Cardiac Troponin, Copeptin, and the Modified HEART Score for Rapid Evaluation of Chest Pain Patients

Disease Markers ◽

10.1155/2018/9136971 ◽

2018 ◽

Vol 2018 ◽

pp. 1-7 ◽

Cited By ~ 1

Author(s):

Beata Morawiec ◽

Brygida Przywara-Chowaniec ◽

Piotr Muzyk ◽

Mariusz Opara ◽

Lam Ho ◽

...

Keyword(s):

Chest Pain ◽

Risk Stratification ◽

Cardiac Troponin ◽

Clinical Performance ◽

Troponin T ◽

High Sensitivity ◽

Short Term ◽

St Segment Elevation ◽

Heart Score ◽

Rule Out

Background. Clinical short-term risk stratification is a recommended approach in patients with chest pain and possible acute myocardial infarction (AMI) to further improve high safety of biomarker-based rule-out algorithms. The study aim was to assess clinical performance of baseline concentrations of high-sensitivity cardiac troponin T (hs-TnT) and copeptin and the modified HEART score (mHS) in early presenters to the emergency department with chest pain. Methods. This cohort study included patients with chest pain with onset maximum of 6 h before admission and no persistent ST-segment elevation on electrocardiogram. hs-TnT, copeptin, and the mHS were assessed from admission data. The diagnostic and prognostic value for three baseline rule-out algorithms: (1) single hs-TnT < 14 ng/l, (2) hs-TnT < 14 ng/l/mHS ≤ 3, and (3) hs-TnT < 14 ng/l/mHS ≤ 3/copeptin < 17.4 pmol/l, was assessed with sensitivity and negative predictive value. Primary diagnostic endpoint was the diagnosis of AMI. Prognostic endpoint was death and/or AMI within 30 days. Results. Among 154 enrolled patients, 44 (29%) were classified as low-risk according to the mHS; AMI was diagnosed in 105 patients (68%). For ruling out AMI, the highest sensitivity and NPV from all studied algorithms were observed for hs-TnT/mHS/copeptin (100%, 95% CI 96.6–100, and 100%, 95% CI 75.3–100). At 30 days, the highest event-free survival was achieved in patients stratified with hs-TnT/mHS/copeptin algorithm (100%) with 100% (95% CI 75.3–100) NPV and 100% (95% CI 96.6–100) sensitivity. Conclusions. The combination of baseline hs-TnT, copeptin, and the mHS has an excellent sensitivity and NPV for short-term risk stratification. Such approach might improve the triage system in emergency departments and be a bridge for inclusion to serial blood sampling algorithms.

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PL001: Derivation of a 2-hour high-sensitivity troponin T algorithm for rapid rule-out of acute myocardial infarction in emergency department chest pain patients

CJEM ◽

10.1017/cem.2016.34 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S29-S29

Author(s):

A. McRae ◽

Y. Ji ◽

H. Yang ◽

D. Southern ◽

D. Wang ◽

...

Keyword(s):

Chest Pain ◽

Troponin T ◽

High Sensitivity ◽

Early Discharge ◽

Coronary Syndrome ◽

Test Characteristics ◽

High Sensitivity Troponin T ◽

Testing Algorithm ◽

Pain Patients ◽

Rule Out

Introduction: Chest pain and symptoms of acute coronary syndrome are responsible for a large proportion of ED visits and acute hospitalizations. However, only about 15% of patients presenting to the ED with high-risk symptoms do, in fact, have an acute coronary syndrome. The objective of this study is to derive a 2-hour high-sensitivity Troponin T (hsTnT) testing algorithm with outcome based-cutoffs to rapidly rule out acute myocardial infarction (AMI) in a large proportion of ED chest pain patients. Methods: Patients included consecutive ED patients with a chief complaint of cardiac chest pain who had an hsTnT assay performed at ED arrival and 2 hours after ED arrival. Administrative databases were queried to identify troponin results and major adverse cardiac outcomes (MACE) including death, MI, and revascularization. Test characteristics of iterative combinations of initial troponin level and absolute change in troponin level were quantified in order to identify the testing algorithm that identified the greatest proportion of patients eligible for early discharge while maintaining a target sensitivity of 98.5% for the primary outcome of 7-day AMI. Results: 755 eligible patients had hsTnT assays performed at ED arrival and at 2 hours. 91 patients (12.1%) had a 7-day AMI while 108 (14.0%) had 7-day MACE. An initial hsTnT level of less than 14 ng/L, in combination with a 2-hour absolute change of less than 10ng/L had a sensitivity of 98.9% (95% CI 94.0,99.8) and an NPV of 99.8% (95% CI 98.7, 100.0) for 7-day AMI. This identified 58.5% of all patients as being suitable for early discharge. Sensitivity and NPV for 7-day MACE were 90.0% (95% CI 83.3, 94.2) and 97.3% (95% CI 95.3,98.4) respectively. Sex-specific differences in test characteristics were not clinically important. Rule-in hsTnT cutoffs were also evaluated, with specificities ranging from 85-95%, although cutoffs with higher specificity had less ability to rapidly rule-in AMI, leaving more patients with indeterminate results after 2 hours. Conclusion: A hsTnT algorithm can safely and accurately rule out AMI in 58.5% of ED chest pain patients within 2 hours of ED arrival. The lower sensitivity of this algorithm for MACE compared to AMI speaks to the importance of clinical assessment and ECG findings in identifying patients at risk for acute coronary syndromes.

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LO10: Low high-sensitivity troponin concentrations identify low-risk chest pain patients unlikely to benefit from further risk stratification

CJEM ◽

10.1017/cem.2020.66 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S10-S10

Author(s):

J. Andruchow ◽

T. Boyne ◽

G. Innes ◽

S. Vatanpour ◽

I. Seiden-Long ◽

...

Keyword(s):

Chest Pain ◽

Risk Stratification ◽

Symptom Onset ◽

Limit Of Detection ◽

Troponin T ◽

High Sensitivity ◽

Low Risk ◽

High Sensitivity Troponin ◽

Pain Patients ◽

Rule Out

Introduction: Very low high-sensitivity troponin-T (hs-cTnT) concentrations on presentation can rule out acute myocardial infarction (AMI), but the ability to identify patients at low risk of 30-day major adverse cardiac events (MACE) is less clear. This study examines the sensitivity of low concentrations of hs-cTnT on presentation to rule out 30-day MACE. Methods: This prospective cohort study enrolled emergency department chest pain patients with non-ischemic ECGs who underwent AMI rule-out with an hs-cTnT assay. The primary outcome was 30-day MACE; secondary outcomes were individual MACE components. Because guidelines recommend using a single hs-cTnT strategy only for patients with more than 3-hours since symptom onset, a subgroup analysis was performed for this population. Outcomes were adjudicated based on review of medical records and telephone follow-up. Results: Of 1,167 patients enrolled, 125 (10.7%) experienced 30-day MACE and 97 (8.3%) suffered AMI on the index visit. More than one-third (35.6%) had presenting hs-cTnT concentrations below the limit of detection (5ng/L), which was 94.4% (95%CI 88.8-97.7%) sensitive for 30-day MACE and 99.0% (95%CI 94.5-100%) sensitive for index AMI. Of 292 (25.0%) patients with hs-cTnT < 5ng/L and at least 3-hours since symptom onset, only 3 experienced 30-day MACE (sensitivity 97.6%, 95%CI 93.2-100%) and none suffered AMI within 30-days (sensitivity 100%, 95%CI 96.3-100%). Conclusion: Among patients with non-ischemic ECGs and >3-hours since symptom onset, low hs-cTnT concentrations on presentation confer a very low risk of 30-day MACE. In the absence of a high risk clinical presentation, further risk stratification is likely to be low yield.

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Chest pain in general practice: a systematic review of prediction rules

BMJ Open ◽

10.1136/bmjopen-2018-027081 ◽

2019 ◽

Vol 9 (2) ◽

pp. e027081 ◽

Cited By ~ 2

Author(s):

Ralf E Harskamp ◽

Simone C Laeven ◽

Jelle CL Himmelreich ◽

Wim A M Lucassen ◽

Henk C P M van Weert

Keyword(s):

Systematic Review ◽

General Practice ◽

Chest Pain ◽

Coronary Disease ◽

Clinical Decision ◽

Clinical Judgement ◽

Predictive Values ◽

Heart Score ◽

Coronary Syndrome ◽

Rule Out

ObjectiveTo identify and assess the performance of clinical decision rules (CDR) for chest pain in general practice.DesignSystematic review of diagnostic studies.Data sourcesMedline/Pubmed, Embase/Ovid, CINAHL/EBSCO and Google Scholar up to October 2018.Study selectionStudies that assessed CDRs for intermittent-type chest pain and for rule out of acute coronary syndrome (ACS) applicable in general practice, thus not relying on advanced laboratory, computer or diagnostic testing.Review methodsReviewers identified studies, extracted data and assessed the quality of the evidence (using Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2)), independently and in duplicate.ResultsEight studies comprising five CDRs met the inclusion criteria. Three CDRs are designed for rule out of coronary disease in intermittent-type chest pain (Gencer rule, Marburg Heart Score, INTERCHEST), and two for rule out of ACS (Grijseels rule, Bruins Slot rule). Studies that examined the Marburg Heart Score had the highest methodological quality with consistent sensitivity (86%–91%), specificity (61%–81%) and positive (23%–35%) and negative (97%–98%) predictive values (PPV and NPV). The diagnostic performance of Gencer (PPV: 20%–34%, NPV: 95%–99%) and INTERCHEST (PPV: 35%–43%, NPV: 96%–98%) appear comparable, but requires further validation. The Marburg Heart Score was more sensitive in detecting coronary disease than the clinical judgement of the general practitioner. The performance of CDRs that focused on rule out of ACS were: Grijseels rule (sensitivity: 91%, specificity: 37%, PPV: 57%, NPV: 82%) and Bruins Slot (sensitivity: 97%, specificity: 10%, PPV: 23%, NPV: 92%). Compared with clinical judgement, the Bruins Slot rule appeared to be safer than clinical judgement alone, but the study was limited in sample size.ConclusionsIn general practice, there is currently no clinical decision aid that can safely rule out ACS. For intermittent chest pain, several rules exist, of which the Marburg Heart Score has been most extensively tested and appears to outperform clinical judgement alone.

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

CJEM ◽

10.1017/cem.2017.159 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S61-S62 ◽

Cited By ~ 1

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.

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Predictive Value of a 6-Hour Ecg/Troponin Protocol in Patients with Chest Pain

Hong Kong Journal of Emergency Medicine ◽

10.1177/102490790301000303 ◽

2003 ◽

Vol 10 (3) ◽

pp. 146-152 ◽

Cited By ~ 1

Author(s):

CY Man ◽

PA Cameron ◽

WL Cheung

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Acute Coronary Syndrome ◽

Chest Pain ◽

Troponin T ◽

Low Risk ◽

Chinese Patients ◽

Initial Assessment ◽

Coronary Syndrome ◽

Pain Patients

Introduction Patients presenting with chest pain and considered to be at low risk of acute coronary syndrome (ACS) may still have coronary heart disease. The potential risk of sudden cardiac death due to arrhythmias or progression to acute myocardial infarction still exists. To minimize this risk, we have designed a 6-hour risk stratification protocol for patients with a low risk of acute myocardial infarction on initial assessment in the Accident and Emergency Department (AED). Materials & Methods This was a retrospective observational study with the aim of determining the risk of adverse cardiovascular events in chest pain patients attending an AED. These patients were subject to an ECG and cardiac troponin T tests (cTnT) at 0 hour and at 6 hours (if the two tests were negative at 0 hour), and were put under observation in the AED observation ward during the same period. The main outcome measures were adverse cardiac events at 30 days. Results A total of 371 Chinese patients considered to have low risk of ACS were recruited into the protocol. Troponin T tested positive in 19 patients (5.1%) at 0 hour and 8 patients (2.2%) at 6 hours. Amongst the 332 patients that were discharged directly from the AED, there were no re-admissions for cardiac-related deaths, acute myocardial infarction, arrhythmia or heart failure. Conclusion The 6-hour ECG and troponin T observation protocol is a useful tool to allow safe discharge of chest pain patients who are at low risk of acute coronary syndrome.

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

Journal of the American Heart Association ◽

10.1161/jaha.121.022539 ◽

2021 ◽

Author(s):

Dustin G. Mark ◽

Jie Huang ◽

Dustin W. Ballard ◽

Mamata V. Kene ◽

Dana R. Sax ◽

...

Keyword(s):

Emergency Department ◽

Cohort Study ◽

Chest Pain ◽

Risk Stratification ◽

Resource Utilization ◽

Coronary Risk ◽

Index Visit ◽

Coronary Syndrome ◽

Estimated Risk ◽

Cardiac Testing

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.

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