Written by Sam Parnell
A 0-hour/1-hour high sensitivity cardiac troponin protocol used in conjunction with the HEART Pathway or EDACS-ADP score had NPV > 99% for 30-day MACE and allowed for safe and rapid rule out for approximately half of patients who presented to the ED with chest pain.
Why does this matter?
Acute coronary syndrome (ACS) is one of the many life-threatening conditions that we must consider when patients present with chest pain. However, most patients with chest pain don’t have ACS. The challenge then becomes how to best determine which patients are otherwise low risk and can safely be discharged home. What would happen if we used a 0-hour and 1-hour high sensitivity troponin (hs-cTnT) protocol combined with commonly used clinical risk tools such as the HEART Pathway (History, ECG, Age, Risk Factors and Troponin) or EDACS-ADP score (Emergency Department Assessment for Chest Pain Score-Accelerated Diagnostic Pathway)?
Don’t tell my HEART, my hs-cTnT negative HEART, I just don’t think ACS will understand…
This was a secondary analysis of data from a prospective observational study including 939 patients who presented with chest pain to a single ED in Sweden between February 2013 and April 2014.
Using the HEART 0-hour/1-hour Pathway, 49.8% of patients were classified as low risk for ACS with a NPV (negative predictive value) of 99.8% and sensitivity of 99.1% for 30-day MACE (major adverse cardiac events). The EDACS-ADP 0-hour/1-hour Pathway identified 49.6% of patients as low risk with NPV of 99.1% and sensitivity of 96.7% for 30-day MACE.
The HEART score alone classified slightly more patients as low risk (53.4%) but had lower NPV (98.8%) and sensitivity (94.8%) for 30-day MACE. Overall, there was no significant difference for 30-day MACE comparing the HEART 0-hour/1-hour group to the EDACS-ADP 0-hour/1-hour group. However, only the HEART 0-hour/1-hour Pathway had both a sensitivity > 99% and an NPV ≥ 99.5% for both 30-day MACE and AMI (acute myocardial infarction).
This study supports a combination of a 0-hour/1-hour high sensitivity cardiac troponin protocol with either the HEART Pathway or EDACS-ADP score for patients presenting with chest pain. This approach appears to lead to safe and rapid discharge for a large number of low risk patients while having high diagnostic accuracy for 30-day MACE.
Check out this thoughtful editorial by Dr. Edward Carlton on whether cardiac risk scores only muddy the waters. Are negative high sensitivity troponin results alone enough to rule out MACE, and what value do risk scores like HEART and EDACS add?
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. Emerg Med J. 2021 Apr 9:emermed-2020-210833. doi: 10.1136/emermed-2020-210833. Epub ahead of print.