Key result
Clinical risk scores alone fail to safely rule out index MI in observation zone patients.
Why the study?
It is unknown whether the mTIMI, HEAR, or sEDACS risk scores can identify a subgroup of observation zone patients without ischemic ECG who have 99% negative predictive value for index MI and can safely be discharged.
Can mTIMI, HEAR, or sEDACS risk scores safely identify patients in the hs-cTnI observation zone without ischemic ECG for discharge with ≥99% NPV for index MI?
Cohort (n=709)
Adjudicators blinded to investigational hs-cTnI measures
Yes
Can mTIMI, HEAR, or sEDACS risk scores safely identify patients in the hs-cTnI observation zone without ischemic ECG for discharge with ≥99% NPV for index MI?
Clinical risk scores (mTIMI, HEAR, sEDACS) alone are insufficient to safely rule out index MI in emergency department patients who fall into the hs-cTnI observation zone without an ischemic ECG, underscoring the need for further testing.
Answers are grounded in this paper and cite their sources.
Risk scores alone should not guide discharge in hs-cTnI observation zone; leaves open whether combined strategies safely rule out MI.
European Society of Cardiology 0/1-hour algorithm is a cardiac troponin-only accelerated diagnostic protocol designed to rapidly rule out or rule in myocardial infarction (MI). However, when the algorithm was applied to the HIGH-US (High-Sensitivity Cardiac Troponin I Assays in the United States) cohort, 37% were risk stratified into the observation zone, indicating diagnostic uncertainty and the need for further evaluation. 1 It is unclear how best to evaluate observation zone patients who are without an ischemic ECG. The 2022 American College of Cardiology Expert Consensus on Chest Pain in the Emergency Department 2 suggests using risk scores to further stratify these patients. However, it is unknown whether the modified Thrombolysis in Myocardial Infarction (mTIMI) score; History, ECG, Age, and Risk factors (HEAR) score; or simplified Emergency Department Assessment of Chest Pain Score (sEDACS) can identify a subgroup with 99% negative predictive value (NPV) for index MI that can be safely discharged from the Emergency Department without additional testing, such as additional serial troponin measures, stress testing, or coronary angiography.
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Ashburn et al. (2023) conducted a cohort in Possible myocardial infarction in the observation zone (n=709). Clinical risk scores (mTIMI, HEAR, sEDACS) was evaluated on Negative predictive value (NPV) ≥99% for index MI (NPV 98.3% (for mTIMI score of 0), 95% CI 90.9-100%). Clinical risk scores (mTIMI, HEAR, sEDACS) alone failed to achieve a ≥99% negative predictive value for index MI to safely rule out events in observation zone patients.
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