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Ratmann PD, Boeddinghaus J, Nestelberger T, Lopez-Ayala P, Huré G, Gehrke J, Koechlin L, Wildi K, Mueller P, Bima P, Wussler D, Gisler N, Miro O, Martín-Sánchez FJ, Christ M, Gualandro DM, Twerenbold R, Gimenez MR, Keller DI, Buser A, Mueller C. Extending the no objective testing rules to patients triaged by the European Society of Cardiology 0/1-hour algorithms. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:834-840. [PMID: 36179255 DOI: 10.1093/ehjacc/zuac120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/04/2022] [Accepted: 09/26/2022] [Indexed: 06/16/2023]
Abstract
AIMS After rule-out of non-ST elevation myocardial infarction (NSTEMI) with the European Society of Cardiology (ESC) 0/1 h-algorithms, it is unclear which patients require further anatomical or functional cardiac testing. To test the safety and efficacy of the no-objective-testing (NOT)-rules after NSTEMI rule-out by the ESC 0/1 h-algorithms. METHODS AND RESULTS International, prospective, diagnostic multicentre study enrolling adult patients presenting with chest pain to the emergency department. Central adjudication of final diagnosis by two independent cardiologists using information including cardiac imaging. Primary endpoints were the safety and efficacy of the NOT-rules for the rule-out of major adverse cardiovascular events (MACE). Secondary endpoints included 365-day and 2-year MACE. Among 4804 and 4569 patients with available 0/1 h high-sensitivity cardiac troponin (hs-cTn)T-Elecsys or hs-cTnI-Architect concentrations, 2783 (58%) and 2252 (49%) were eligible for application of the NOT-rules after rule-out of NSTEMI by the ESC hs-cTnT/I-0/1h-algorithm. The first rule identified 26% of patients with a sensitivity of 100% (95%CI 98.3-100%) and a negative predictive value (NPV) of 100% (95% CI, n.c.). The second and third rules both identified 31% of patients with a sensitivity of 99.5% (95% CI 97.4-99.9%) and a NPV of 99.9% (95% CI 99.2-99.9%). Similar findings emerged for hs-cTnI. High safety was confirmed for rule-out of 365-day and 2-year MACE and proven to be superior to the HEART Score. CONCLUSION All three NOT-rules performed very well for rule-out of MACE. The third NOT-rule best balanced feasibility, safety, and efficacy by identifying nearly one out of three patients as low-risk and may not require further cardiac testing. https://clinicaltrials.gov/ct2/show/NCT00470587.
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Affiliation(s)
- Paul David Ratmann
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT network, Via Antonio Serra, 54, 00191 Rome, Italy
| | - Jasper Boeddinghaus
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT network, Via Antonio Serra, 54, 00191 Rome, Italy
| | - Thomas Nestelberger
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT network, Via Antonio Serra, 54, 00191 Rome, Italy
| | - Pedro Lopez-Ayala
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT network, Via Antonio Serra, 54, 00191 Rome, Italy
| | - Gabrielle Huré
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | - Juliane Gehrke
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT network, Via Antonio Serra, 54, 00191 Rome, Italy
| | - Luca Koechlin
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT network, Via Antonio Serra, 54, 00191 Rome, Italy
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | - Karin Wildi
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT network, Via Antonio Serra, 54, 00191 Rome, Italy
- Critical Care Research Group, The Prince Charles Hospital, Brisbane and the University of Queensland, 627 Rode Rd, Chermside Queensland 4032, Australia
| | - Philip Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT network, Via Antonio Serra, 54, 00191 Rome, Italy
| | - Paolo Bima
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT network, Via Antonio Serra, 54, 00191 Rome, Italy
| | - Desiree Wussler
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT network, Via Antonio Serra, 54, 00191 Rome, Italy
| | - Nicolas Gisler
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT network, Via Antonio Serra, 54, 00191 Rome, Italy
| | - Oscar Miro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT network, Via Antonio Serra, 54, 00191 Rome, Italy
- Emergency Department, Hospital Clinic, C. de Villarroel 170, 08036 Barcelona, Spain
| | - F Javier Martín-Sánchez
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT network, Via Antonio Serra, 54, 00191 Rome, Italy
- Emergency Department, Hospital Clínico San Carlos, Calle del Prof Martín Lagos, S/N, 28040 Madrid, Spain
| | - Michael Christ
- Department of Emergency Medicine, Luzerner Kantonsspital, Spitalstrasse 16, CH-6000 Luzern, Switzerland
| | - Danielle M Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT network, Via Antonio Serra, 54, 00191 Rome, Italy
| | - Raphael Twerenbold
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT network, Via Antonio Serra, 54, 00191 Rome, Italy
| | - Maria Rubini Gimenez
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- Cardiology Department, Heart Center Leipzig, Strümpellstraße 39, D-04289 Leipzig, Germany
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Schmelzbergstrasse 8, CH-8091 Zurich, Switzerland
| | - Andreas Buser
- Blood Transfusion Centre, Swiss Red Cross, Hebelstrasse 10, CH-4056 Basel, Switzerland
- Department of Hematology, University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Petersgraben 4, CH-4031 Basel, Switzerland
- GREAT network, Via Antonio Serra, 54, 00191 Rome, Italy
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Anderson HVS, Masri SC, Abdallah MS, Chang AM, Cohen MG, Elgendy IY, Gulati M, LaPoint K, Madan N, Moussa ID, Ramirez J, Simon AW, Singh V, Waldo SW, Williams MS. 2022 ACC/AHA Key Data Elements and Definitions for Chest Pain and Acute Myocardial Infarction: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Data Standards. J Am Coll Cardiol 2022; 80:1660-1700. [PMID: 36055903 DOI: 10.1016/j.jacc.2022.05.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Aung SSM, Roongsritong C. A Closer Look at the HEART Score. Cardiol Res 2022; 13:255-263. [PMID: 36405228 PMCID: PMC9635776 DOI: 10.14740/cr1432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/13/2022] [Indexed: 01/25/2023] Open
Abstract
The history, electrocardiogram, age, risk factors, and troponin (HEART) score is currently a widely used tool for acute chest pain risk stratification. Relatively soon after its inception in 2008, a number of validation studies on the HEART score showed it to be superior to Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) scores and at least as accurate to other existing scores for predicting short-term major adverse cardiovascular events (MACEs). However, partly due to its focus on simplicity, the HEART score has some limitations. In this article we review how the HEART score has evolved and taken on various modifications to circumvent some of its limitations. We also highlight the strength of the HEART score in comparison with other risk stratification tools and the current guidelines.
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Affiliation(s)
- Sammy San Myint Aung
- Department of Internal Medicine, Cornwall Regional Hospital, Montego Bay, Jamaica,Corresponding Author: Sammy San Myint Aung, Department of Internal Medicine, Cornwall Regional Hospital, Montego Bay, Jamaica.
| | - Chantwit Roongsritong
- Division of Cardiology, Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX 79905, USA
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Cardiovasc Comput Tomogr 2022; 16:54-122. [PMID: 34955448 DOI: 10.1016/j.jcct.2021.11.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:e187-e285. [PMID: 34756653 DOI: 10.1016/j.jacc.2021.07.053] [Citation(s) in RCA: 301] [Impact Index Per Article: 100.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:2218-2261. [PMID: 34756652 DOI: 10.1016/j.jacc.2021.07.052] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This executive summary of the clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. These guidelines present an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated and shared decision-making with patients is recommended.
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709879 DOI: 10.1161/cir.0000000000001029] [Citation(s) in RCA: 135] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709928 DOI: 10.1161/cir.0000000000001030] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM This executive summary of the clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. These guidelines present an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated and shared decision-making with patients is recommended.
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Stopyra JP, Snavely AC, Smith LM, Harris RD, Nelson RD, Winslow JE, Alson RL, Pomper GJ, Riley RF, Ashburn NP, Hendley NW, Gaddy J, Woodrum T, Fornage L, Conner D, Alvarez M, Pflum A, Koehler LE, Miller CD, Mahler SA. Prehospital use of a modified HEART Pathway and point-of-care troponin to predict cardiovascular events. PLoS One 2020; 15:e0239460. [PMID: 33027260 PMCID: PMC7540888 DOI: 10.1371/journal.pone.0239460] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 09/06/2020] [Indexed: 12/27/2022] Open
Abstract
The HEART Pathway is a validated risk stratification protocol for Emergency Department patients with chest pain that has yet to be tested in the prehospital setting. This study seeks to test the performance of a prehospital modified HEART Pathway (PMHP). A prospective cohort study of adults with chest pain without ST-segment elevation myocardial infarction was conducted at three EMS agencies between 12/2016-1/2018. To complete a PMHP assessment, paramedics drew blood, measured point-of-care (POC) troponin (i-STAT; Abbott Point of Care) and calculated a HEAR score. Patients were stratified into three groups: high-risk based on an elevated troponin, low-risk based on a HEAR score <4 with a negative troponin, or moderate risk for a HEAR score ≥4 with a negative troponin. Sensitivity, specificity, negative and positive predictive values of the PMHP for detection of major adverse cardiac events (MACE: cardiac death, MI, or coronary revascularization) at 30-days were calculated. A total of 506 patients were accrued, with PMHP completed in 78.1% (395/506). MACE at 30-days occurred in 18.7% (74/395). Among these patients, 7.1% (28/395) were high risk yielding a specificity and PPV for 30-day MACE of 96.6% (95%CI: 94.0–98.3%) and 60.7% (95%CI: 40.6–78.6%) respectively. Low-risk assessments occurred in 31.4% (124/395), which were 90.5% (95%CI: 81.5–96.1%) sensitive for 30-day MACE with a NPV of 94.4% (95%CI: 88.7–97.7%). Moderate-risk assessments occurred in 61.5% (243/395), of which 20.6% had 30-day MACE. The PMHP is able to identify high-risk and low-risk groups with high specificity and negative predictive value for 30-day MACE.
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Affiliation(s)
- Jason P. Stopyra
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States of America
- * E-mail:
| | - Anna C. Snavely
- Department of Biostatistics, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Lane M. Smith
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States of America
| | - R. David Harris
- Forsyth County Emergency Services, Forsyth County Government, Winston-Salem, North Carolina, United States of America
| | - Robert D. Nelson
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States of America
| | - James E. Winslow
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Roy L. Alson
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Gregory J. Pomper
- Department of Pathology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Robert F. Riley
- Department of Cardiology, The Christ Hospital Heart and Vascular Center, Cincinnati, Ohio, United States of America
| | - Nicklaus P. Ashburn
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Nella W. Hendley
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Jeremiah Gaddy
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Tyler Woodrum
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Louis Fornage
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - David Conner
- Department of Emergency Medicine, Duke University, Durham, North Carolina, United States of America
| | - Manrique Alvarez
- Department of Cardiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Adam Pflum
- Department of Cardiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Lauren E. Koehler
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Chadwick D. Miller
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Simon A. Mahler
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States of America
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Ruangsomboon O, Thirawattanasoot N, Chakorn T, Limsuwat C, Monsomboon A, Praphruetkit N, Surabenjawong U, Riyapan S, Nakornchai T. The utility of the 1-hour high-sensitivity cardiac troponin T algorithm compared with and combined with five early rule-out scores in high-acuity chest pain emergency patients. Int J Cardiol 2020; 322:23-28. [PMID: 32882291 DOI: 10.1016/j.ijcard.2020.08.099] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 06/12/2020] [Accepted: 08/24/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although the 0/1 h high-sensitivity cardiac troponin T (0/1 hs-cTnT) algorithm and many risk scores have been validated for use in emergency departments (EDs), their utility in high-acuity ED patients has not been validated. We aimed to validate the 0/1 hs-cTnT algorithm and the HEART, TIMI, GRACE, T-MACS and NOTR risk scores before and after combining the 0/1 algorithm in high-acuity ED chest pain patients. METHODS A prospective observational study was conducted in the high-acuity ED of Siriraj Hospital, a tertiary hospital in Bangkok, Thailand. Adult patients with chest pain were enrolled between November 2018 and November 2019. The primary outcome was 30-day major adverse cardiac events (30-day MACE), defined as a composite of mortality, acute myocardial infarction, significant coronary stenosis and revascularization procedures. RESULTS Of 350 recruited patients, 59 (16.9%) developed 30-day MACE. For the 0/1 hs-cTnT algorithm, sensitivity and negative predictive value (NPV) were 91.3% (95%CI 79.2-97.6%) and 97.2% (95%CI 93.2-98.9%), respectively. Specificity and positive predictive value were 79.6% (95%CI 72.8-85.2%) and 53.9% (95%CI 46.2-61.3%), respectively. Of the risk scores, the HEART score had the highest area under the receiver operator characteristic curve (0.74 [95%CI 0.68-0.81]). Combining the 0/1 hs-cTnT algorithm, a TIMI score cut-off of ≤1 had the best sensitivity and NPV (both 100%) and identified the greatest proportion of patients (24.3%) suitable for safe discharge. CONCLUSION The 0/1 hs-cTnT algorithm may be feasible in Asian high-acuity ED patients. The HEART score outperformed other scores in predicting 30-day MACE. Combining the 0/1 hs-cTnT algorithm with a TIMI cut-off score ≤ 1 had the best rule-out performance.
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Affiliation(s)
- Onlak Ruangsomboon
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand.
| | - Netiporn Thirawattanasoot
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
| | - Tipa Chakorn
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
| | - Chok Limsuwat
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
| | - Apichaya Monsomboon
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
| | - Nattakarn Praphruetkit
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
| | - Usapan Surabenjawong
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
| | - Sattha Riyapan
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
| | - Tanyaporn Nakornchai
- Department of Emergency Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, Bangkoknoi 10700, Thailand
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Stopyra JP, Riley RF, Hiestand BC, Russell GB, Hoekstra JW, Lefebvre CW, Nicks BA, Cline DM, Askew KL, Elliott SB, Herrington DM, Burke GL, Miller CD, Mahler SA. The HEART Pathway Randomized Controlled Trial One-year Outcomes. Acad Emerg Med 2019; 26:41-50. [PMID: 29920834 DOI: 10.1111/acem.13504] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/01/2018] [Accepted: 06/07/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The objective was to determine the impact of the HEART Pathway on health care utilization and safety outcomes at 1 year in patients with acute chest pain. METHODS Adult emergency department (ED) patients with chest pain (N = 282) were randomized to the HEART Pathway or usual care. In the HEART Pathway arm, ED providers used the HEART score and troponin measures (0 and 3 hours) to risk stratify patients. Usual care was based on American College of Cardiology/American Heart Association guidelines. Major adverse cardiac events (MACE-cardiac death, myocardial infarction [MI], or coronary revascularization), objective testing (stress testing or coronary angiography), and cardiac hospitalizations and ED visits were assessed at 1 year. Randomization arm outcomes were compared using Fisher's exact tests. RESULTS A total of 282 patients were enrolled, with 141 randomized to each arm. MACE at 1 year occurred in 10.6% (30/282): 9.9% in the HEART Pathway arm (14/141; 10 MIs, four revascularizations without MI) versus 11.3% in usual care (16/141; one cardiac death, 13 MIs, two revascularizations without MI; p = 0.85). Among low-risk HEART Pathway patients, 0% (0/66) had MACE, with a negative predictive value (NPV) of 100% (95% confidence interval = 93%-100%). Objective testing through 1 year occurred in 63.1% (89/141) of HEART Pathway patients compared to 71.6% (101/141) in usual care (p = 0.16). Nonindex cardiac-related hospitalizations and ED visits occurred in 14.9% (21/141) and 21.3% (30/141) of patients in the HEART Pathway versus 10.6% (15/141) and 16.3% (23/141) in usual care (p = 0.37, p = 0.36). CONCLUSIONS The HEART Pathway had a 100% NPV for 1-year safety outcomes (MACE) without increasing downstream hospitalizations or ED visits. Reduction in 1-year objective testing was not significant.
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Affiliation(s)
- Jason P. Stopyra
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Robert F. Riley
- The Christ Hospital Heart and Vascular Center and Lindner Center for Research and Education Cincinnati OH
| | - Brian C. Hiestand
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Gregory B. Russell
- Department of Biostatistical Sciences Wake Forest School of Medicine Winston‐Salem NC
| | - James W. Hoekstra
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Cedric W. Lefebvre
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Bret A. Nicks
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - David M. Cline
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Kim L. Askew
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Stephanie B. Elliott
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - David M. Herrington
- Department of Biostatistical Sciences Wake Forest School of Medicine Winston‐Salem NC
| | - Gregory L. Burke
- Department of Internal Medicine Division of Cardiology Wake Forest School of Medicine Winston‐Salem NC
- Public Health Sciences Wake Forest School of Medicine Winston‐Salem NC
| | - Chadwick D. Miller
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
| | - Simon A. Mahler
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐Salem NC
- Departments of Implementation Science and Epidemiology and Prevention Wake Forest School of Medicine Winston‐Salem NC
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Summers SM, Long B, April MD, Koyfman A, Hunter CJ. High sensitivity troponin: The Sisyphean pursuit of zero percent miss rate for acute coronary syndrome in the ED. Am J Emerg Med 2018; 36:1088-1097. [DOI: 10.1016/j.ajem.2018.03.075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 03/22/2018] [Accepted: 03/28/2018] [Indexed: 10/17/2022] Open
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Greenslade JH, Carlton EW, Van Hise C, Cho E, Hawkins T, Parsonage WA, Tate J, Ungerer J, Cullen L. Diagnostic Accuracy of a New High-Sensitivity Troponin I Assay and Five Accelerated Diagnostic Pathways for Ruling Out Acute Myocardial Infarction and Acute Coronary Syndrome. Ann Emerg Med 2017; 71:439-451.e3. [PMID: 29248334 DOI: 10.1016/j.annemergmed.2017.10.030] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 10/26/2017] [Accepted: 10/27/2017] [Indexed: 10/18/2022]
Abstract
STUDY OBJECTIVE This diagnostic accuracy study describes the performance of 5 accelerated chest pain pathways, calculated with the new Beckman's Access high-sensitivity troponin I assay. METHODS High-sensitivity troponin I was measured with presentation and 2-hour blood samples in 1,811 patients who presented to an emergency department (ED) in Australia. Patients were classified as being at low risk according to 5 rules: modified accelerated diagnostic protocol to assess patients with chest pain symptoms using troponin as the only biomarker (m-ADAPT), the Emergency Department Assessment of Chest Pain Score (EDACS) pathway, the History, ECG, Age, Risk Factors, and Troponin (HEART) pathway, the No Objective Testing Rule, and the new Vancouver Chest Pain Rule. Endpoints were 30-day acute myocardial infarction and acute coronary syndrome. Measures of diagnostic accuracy for each rule were calculated. RESULTS Data included 96 patients (5.3%) with acute myocardial infarction and 139 (7.7%) with acute coronary syndrome. The new Vancouver Chest Pain Rule and No Objective Testing Rule had high sensitivity for acute myocardial infarction (100%; 95% confidence interval [CI] 96.2% to 100% for both) and acute coronary syndrome (98.6% [95% CI 94.9% to 99.8%] and 99.3% [95% CI 96.1% to 100%]). The m-ADAPT, EDACS, and HEART pathways also yielded high sensitivity for acute myocardial infarction (96.9% [95% CI 91.1% to 99.4%] for m-ADAPT and 97.9% [95% CI 92.7% to 99.7%] for EDACS and HEART), but lower sensitivity for acute coronary syndrome (≤95.0% for all). The m-ADAPT, EDACS, and HEART rules classified more patients as being at low risk (64.3%, 62.5%, and 49.8%, respectively) than the new Vancouver Chest Pain Rule and No Objective Testing Rule (28.2% and 34.5%, respectively). CONCLUSION In this cohort with a low prevalence of acute myocardial infarction and acute coronary syndrome, using the Beckman's Access high-sensitivity troponin I assay with the new Vancouver Chest Pain Rule or No Objective Testing Rule enabled approximately one third of patients to be safely discharged after 2-hour risk stratification with no further testing. The EDACS, m-ADAPT, or HEART pathway enabled half of ED patients to be rapidly referred for objective testing.
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Affiliation(s)
- Jaimi H Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia; School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.
| | - Edward W Carlton
- Emergency Department, South Meade Hospital, North Bristol National Health Service Trust, Bristol, United Kingdom
| | - Christopher Van Hise
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Elizabeth Cho
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Tracey Hawkins
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - William A Parsonage
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia; School of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Jillian Tate
- Pathology Queensland, Herston, Queensland, Australia
| | | | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia; School of Medicine, The University of Queensland, Brisbane, Queensland, Australia; Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
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Stopyra JP, Miller CD, Mahler SA. In Reply. Acad Emerg Med 2017; 24:1171-1172. [PMID: 28608431 DOI: 10.1111/acem.13239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
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Greenslade J, Cullen L. Comparing the No Objective Testing Rule to the HEART Pathway. Acad Emerg Med 2017; 24:1169-1170. [PMID: 28608494 DOI: 10.1111/acem.13240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jaimi Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
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