Performance of the EDACS-accelerated Diagnostic Pathway in a Cohort of US Patients with Acute Chest Pain

Abstract

Background The Emergency Department Assessment of Chest pain Score – Accelerated Diagnostic Protocol (EDACS-ADP) is a decision aid designed to safely identify Emergency Department (ED) patients with chest pain for early discharge. Derivation and validation studies in Australasia have demonstrated high sensitivity (99-100%) for major adverse cardiac events (MACE). Objectives To validate the EDACS-ADP in a cohort of US ED patients with symptoms suspicious for acute coronary syndrome (ACS). Methods A secondary analysis of participants enrolled in the HEART Pathway Randomized Controlled Trial was conducted. This single-site trial enrolled 282 ED patients ≥ 21 years old with symptoms concerning for ACS, inclusive of all cardiac risk levels. Each patient was classified as low-risk or at-risk by the EDACS-ADP based on EDACS, ECG, and serial troponins. Potential early discharge rate and sensitivity for MACE at 30 days, defined as cardiac death, myocardial infarction (MI), or coronary revascularization were calculated. Results MACE occurred in 17/282 (6.0%) participants, including no deaths, 16/282 (5.6%) with MI, and 1/282 (0.4%) with coronary revascularization without MI. The EDACS-ADP identified 188/282 patients (66.7%, 95% CI 60.8-72.1%) as low-risk. Of these, 2/188 (1.1%, 95% CI 0.1-3.9%) had MACE at 30 days. EDACS-ADP was 88.2% (95% CI 63.6-98.5%) sensitive for MACE, identifying 15/17 patients. Of the 2 patients identified as low-risk with MACE, 1 had MI and 1 had coronary revascularization without MI. Conclusions Within a US cohort of ED patients with symptoms concerning for ACS, sensitivity for MACE was 88.2%. We are unable to validate the EDACS-ADP as sufficiently sensitive for clinical use.

Undetectable Concentrations of a Food and Drug Administration–approved High‐sensitivity Cardiac Troponin T Assay to Rule Out Acute Myocardial Infarction at Emergency Department Arrival

“…However, the triage complaints of chest pain–cardiac features and cardiac‐type pain used to identify patients correspond to the AHA research definition of potential ACS symptoms and has been shown to have both construct and outcome validity . We are reassured that patient demographics and outcome rates are similar to other North American cohorts and that the hsTnT assay's test characteristics are preserved in a higher‐risk subgroup. We caution that because the inclusion criteria focused on anginal‐type pain, these findings may not be generalizable to patients with atypical primary symptoms such as dyspnea or nausea.…”

Observation Status or Inpatient Admission: Impact of Patient Disposition on Outcomes and Utilization Among Emergency Department Patients With Chest Pain

“…The goal of the evaluation of a patient who presents to the ED with chest pain has changed from diagnosis to risk stratification. The use of the History, Electrocardiogram, Age, Risk Factors, Troponin (HEART) or Thrombolysis in Myocardial Infarction (TIMI) risk scores, provide diagnostic information, among others, unfortunately in our study, the history, electrocardiogram, and troponin are not elements available for matching.…”

“…The goal of the evaluation of a patient who presents to the ED with chest pain has changed from diagnosis to risk stratification. The use of the History, Electrocardiogram, Age, Risk Factors, Troponin (HEART) or Thrombolysis in Myocardial Infarction (TIMI) risk scores, provide diagnostic information, 22 among others, [23][24][25][26][27][28][29][30] unfortunately in our study, the history, electrocardiogram, and troponin are not elements available for matching. The use of observation, in the case of chest pain, is to evaluate patients with both intermediate and low probability of acute coronary syndrome, and this risk is likely to influence the evaluation that the patient will receive.…”

Sex-specific, high-sensitivity cardiac troponin T cut-off concentrations for ruling out acute myocardial infarction with a single measurement

“…22 Moreover, the patient demographics and 7-day MI incidence are similar to other North American cohorts. 23,24 Because the inclusion criteria focused on chest pain, these findings may not be generalizable to patients with other symptoms of ACS, such as dyspnea or nausea.…”