Comparison of accelerated diagnostic pathways for acute chest pain risk stratification

Abstract

BackgroundThe History Electrocardiogram Age Risk factor Troponin (HEART) Pathway and Emergency Department Assessment of Chest pain Score (EDACS) are validated accelerated diagnostic pathways designed to risk stratify patients presenting to the emergency department with chest pain. Data from large multisite prospective studies comparing these accelerated diagnostic pathways are limited.MethodsThe HEART Pathway Implementation is a prospective three-site cohort study, which accrued adults with symptoms concerning for acute coronary syndrome. Physicians completed electronic health record HEART Pathway and EDACS risk assessments on participants. Major adverse cardiac events (death, myocardial infarction and coronary revascularisation) at 30 days were determined using electronic health record, insurance claims and death index data. Test characteristics for detection of major adverse cardiac events were calculated for both accelerated diagnostic pathways and McNemar’s tests were used for comparisons.Results5799 patients presenting to the emergency department were accrued, of which HEART Pathway and EDACS assessments were completed on 4399. Major adverse cardiac events at 30 days occurred in 449/4399 (10.2%). The HEART Pathway identified 38.4% (95% CI 37.0% to 39.9%) of patients as low-risk compared with 58.1% (95% CI 56.6% to 59.6%) identified as low-risk by EDACS (p<0.001). Major adverse cardiac events occurred in 0.4% (95% CI 0.2% to 0.9%) of patients classified as low-risk by the HEART Pathway compared with 1.0% (95% CI 0.7% to 1.5%) of patients identified as low-risk by EDACS (p<0.001). Thus, the HEART Pathway had a negative predictive value of 99.6% (95% CI 99.1% to 99.8%) for major adverse cardiac events compared with a negative predictive value of 99.0% (95% CI 98.5% to 99.3%) for EDACS.ConclusionsEDACS identifies a larger proportion of patients as low-risk than the HEART Pathway, but has a higher missed major adverse cardiac events rate at 30 days. Physicians will need to consider their risk tolerance when deciding whether to adopt the HEART Pathway or EDACS accelerated diagnostic pathway.Trial registration numberNCT02056964.

Automated Retrospective Calculation of the EDACS and HEART Scores in a Multicenter Prospective Cohort of Emergency Department Chest Pain Patients

“…However, the patient sample appears demographically comparable to ED adult patients with chest pain and normal troponin measurements from a large retrospective cohort in the same integrated health system (median age = 58 years vs. 59 years, diabetes 23% vs. 24%, coronary artery disease in 15% vs. 19%), suggesting minimal selection bias 15 . In addition, the proportion of patients categorized as low risk by the EDACS‐ADP and HEART pathway are comparable to other prospective studies in North America 7,10,30 . The observation that a higher proportion of patients with RISTRA data were directly discharged from the ED compared to patients without RISTRA data comports with more selective use of RISTRA in patients without perceived clear indications for observation or admission, supported by the nearly threefold lower proportion of patients with RISTRA data who had elevated troponin measurements (Data Supplement S1, Table S1).…”

“…15 In addition, the proportion of patients categorized as low risk by the EDACS-ADP and HEART pathway are comparable to other prospective studies in North America. 7,10,30 The observation that a higher proportion of patients with RISTRA data were directly discharged from the ED compared to patients without RISTRA data comports with more selective use of RISTRA in patients without perceived clear indications for observation or admission, supported by the nearly threefold lower proportion of patients with RISTRA data who had elevated troponin measurements (Data Supplement S1, Table S1). While this imbalance might be interpreted as evidence of sampling bias, it can alternatively be viewed as an indication that the RISTRA use patients are more representative of the underdifferentiated chest pain patient population with possible ACS for whom eCDS use is most likely to impact care.…”

Predictive risk stratification using HEART (history, electrocardiogram, age, risk factors, and initial troponin) and TIMI (thrombolysis in myocardial infarction) scores in non-high risk chest pain patients

“…There is evolving demand for easy and rapid evaluation protocols, such as the use of coronary computerized tomography (CT) angiography [27] and identification of patients who might safely defer stress testing. [28] Cardiac risk scores are generally used to identify such patients who may be eligible for these protocols. [26,27] With further evidence from DCA, we can triage eligible patients who will benefit from requiring the scoring tool and further evaluation strategies (e.g., stress test vs. no stress test in low-risk patients).…”

“…Lastly, since this is a single center medical chart review of data on majority low risk AA subjects, generalizability of the results may be limited in other racial groups across other practices, but the superiority of c-statistic of HEART risk scores in addition to high Sn and NPV of HEART score for 6-week MACE outcome to TIMI score from our study is consistent with prior published reports. [10,28]…”

Heartbeat: Rapid rule-out pathways for acute myocardial infarction

“…Stopyra and colleagues3 compared two other rapid rule-out pathways for AMI in 5788 patients presenting to the emergency department at three sites in the USA. The History ECG Age Risk factor Troponin (HEART) Pathway classified 38% of patients as low-risk and only 0.4% of these low risk patient had a major adverse cardiac event (MACE) at 30 days; a negative predictive value of 99.6%.…”