Derivation of a HEAR Pathway for Emergency Department Chest Pain Patients to Safely Avoid a Second Troponin Test

Q: What are the key findings of this study?

The HEAR pathway ruled out index NSTEMI in 21.0% of chest pain patients with 100.0% NPV (95% CI 99.8-100.0%), reducing second troponin tests by 18.2% (95% CI 17.4-19.1%) vs the LoD strategy.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Acute chest pain with suspected non-ST elevation myocardial infarction (NSTEMI) (n=7131). Intervention: HEAR pathway (low-risk HEAR score 0-2 plus 0 h hs-cTnT < 14 ng/L) vs. 0 h hs-cTnT < limit of detection (< 5 ng/L) strategy, HEART pathway, and EDACS-ADP. Primary outcome: Rule-out of index visit NSTEMI at 0 hours (proportion ruled out and negative predictive value) (ARR 18.2%, 95% CI 17.4-19.1).

Q: What does this research mean for the field?

A HEAR-based pathway combining a low HEAR score with initial hs-cTnT safely rules out index NSTEMI with 100.0% negative predictive value, reducing the need for repeat troponin testing by 18.2% compared to standard limit of detection strategies. Novelty: ClaimNovelty.METHODOLOGICAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To develop and evaluate a clinical decision pathway based on the HEAR score and baseline high-sensitivity cardiac troponin T to safely avoid a second troponin test in emergency department patients with suspected non-ST elevation myocardial infarction.

Chen Chen; Yu Yao; Dongxu Chen; C. Cai; Yannan Zhou; Fengqing Liao; Alima Humarbek; Xuan Li; Zhenju Song; Zhan Sun; Chaoyang Tong; Chenling Yao; Guorong Gu

doi:10.3390/diagnostics13203217

October 16, 2023DiagnosticsOpen Access

Derivation of a HEAR Pathway for Emergency Department Chest Pain Patients to Safely Avoid a Second Troponin Test

View Full Paper

Ask AI

Bookmark

Share

Key result

HEAR pathway cuts second troponin testing by an absolute ~18% vs LoD strategy.

Figures

Why the study?

The study aimed to develop a decision pathway combining the HEAR score and 0 h hs-cTnT to safely avoid a second troponin test for suspected NSTEMI in emergency departments.

Does a Bayesian-derived HEAR pathway (HEAR score 0-2 plus 0 h hs-cTnT <14 ng/L) safely reduce the need for a second troponin test while ruling out index NSTEMI compared with the 0 h hs-cTnT <5 ng/L LoD strategy in emergency department patients with acute chest pain?

Key Points

To develop and evaluate a clinical decision pathway based on the HEAR score and baseline high-sensitivity cardiac troponin T to safely avoid a second troponin test in emergency department patients with suspected non-ST elevation myocardial infarction.
Retrospective derivation cohort of 7131 emergency department chest pain patients evaluated for suspected non-ST elevation myocardial infarction (NSTEMI).
Applied a Bayesian approach combining the HEAR score (history, electrocardiogram, age, risk factors) with 0 h high-sensitivity cardiac troponin T (hs-cTnT) to identify low-risk patients.
For patients classified as low risk (HEAR score 0 to 2 and 0 h hs-cTnT <14 ng/L), the negative predictive value for index visit NSTEMI was 100.0% (95% CI, 99.8% to 100.0%) and the false-negative rate for 180-day major adverse cardiovascular events (MACE) was 0.40% (95% CI, 0.18% to 0.87%).
The HEAR pathway ruled out 1496 (21.0%) patients at 0 h with 100.0% sensitivity (95% CI, 99.4–100.0%) for index visit NSTEMI, missing 6 patients (0.4%) with 180-day MACE.
Compared with the limit-of-detection strategy (<5 ng/L), the pathway correctly reclassified 1298 patients without MACE as low risk, producing an 18.2% decrease (95% CI, 17.4-19.1%) in the need for a second troponin test.

Study Design

Type

Cohort (n=7,131)

Multicenter

No

Structured PICO

Does a Bayesian-derived HEAR pathway (HEAR score 0-2 plus 0 h hs-cTnT <14 ng/L) safely reduce the need for a second troponin test while ruling out index NSTEMI compared with the 0 h hs-cTnT <5 ng/L LoD strategy in emergency department patients with acute chest pain?

P

Population

7,131 adults (median age 64 years, 45.1% female) presenting to a Chinese emergency department with acute chest pain and suspected NSTEMI, followed for 180 days.

E

Exposure

HEAR pathway: structured pretest probability assessment using the HEAR score (History, ECG, Age, Risk factors; score 0-2 considered low risk) combined with a single initial 0-hour high-sensitivity cardiac troponin T (hs-cTnT) <14 ng/L (99th percentile URL) to recommend early ED discharge without a second troponin test.

C

Comparator

Standard 0-hour hs-cTnT below limit of detection (LoD) strategy (chest pain onset >3 h and 0 h hs-cTnT <5 ng/L), the HEART pathway (HEART score 0-3 and negative serial troponins), and the EDACS-accelerated diagnostic protocol (EDACS <16 with non-ischemic ECG and negative serial troponins).

O

Outcome

Clinical diagnosis of index visit NSTEMI (adjudicated by two independent physicians and a third cardiologist in case of disagreement based on clinical records through 180 days) and the proportion of patients safely ruled out at 0 hours avoiding a second troponin test.hard clinical

Main Result

Absolute Risk Reduction: 18.2 (95% CI 17.4–19.1)

Absolute Event Rate: 21% vs 2.7%

Absolute Risk Reduction: 18.2%

Combining a low-risk clinical HEAR score (0-2) with an initial 0-hour hs-cTnT <14 ng/L safely rules out NSTEMI in 21% of ED chest pain patients with 100% negative predictive value, reducing the need for a second troponin test by 18.2% compared with the standard <5 ng/L limit-of-detection cutoff.

Limitations

Single-center, retrospective study design limiting generalizability
Lack of external validation and prospective validation
Potential selection bias due to patients lost to follow-up having lower baseline risk and lower index NSTEMI prevalence
Use of electronic medical record review as a surrogate for telephone follow-up when patients could not be contacted
Cohort NSTEMI prevalence was 8.2%, so caution is required in populations with higher NSTEMI prevalence
Single-center, retrospective design limiting generalizability and requiring external and prospective validation
Potential selection bias from patients lost to follow-up, who had lower HEAR/HEART scores and lower index NSTEMI prevalence (3.2% vs 8.2%)
Electronic medical record review used as a surrogate for telephone follow-up in unreachable patients, potentially leading to incomplete outcome capture
Derived in a cohort with an 8.2% NSTEMI prevalence, requiring caution in higher-prevalence populations

Implication

May reduce repeat troponin testing in low-risk ED chest pain; leaves open randomized validation before practice change.

Abstract

The study aims to develop a decision pathway based on HEAR score and 0 h high-sensitivity cardiac troponin T (hs-cTnT) to safely avoid a second troponin test for suspected non-ST elevation myocardial infarction (NSTEMI) in emergency departments. A HEAR score consists of history, electrocardiogram, age, and risk factors. A HEAR pathway is established using a Bayesian approach based on a predefined safety threshold of NSTEMI prevalence in the rule-out group. In total, 7131 patients were retrospectively enrolled, 582 (8.2%) with index visit NSTEMI and 940 (13.2%) with 180-day major adverse cardiovascular events (MACE). For patients with a low-risk HEAR score (0 to 2) and low 0 h hs-cTnT (<14 ng/L), the HEAR pathway recommends early discharge without further testing. After the HEAR pathway had been applied to rule out NSTEMI, the negative predictive value of index visit NSTEMI was 100.0% (95% CI, 99.8% to 100.0%) and false-negative rate of 180-day MACE was 0.40% (95% CI, 0.18% to 0.87%). Compared with the 0 h hs-cTnT < limit of detection (LoD) strategy (<5 ng/L), the HEAR pathway could correctly reclassify 1298 patients without MACE as low risk and lead to a 18.2% decrease (95% CI, 17.4-19.1%) in the need for a second troponin test. The HEAR pathway may lead to a substantial and safe reduction in repeated troponin test for emergency department patients with suspected NSTEMI.

Discussion

No takes yet. Share an insight, caveat, or question.

Cite This Study

Chen et al. (2023) conducted a cohort in Acute chest pain with suspected non-ST elevation myocardial infarction (NSTEMI) (n=7,131). HEAR pathway (low-risk HEAR score 0-2 plus 0 h hs-cTnT < 14 ng/L) vs. 0 h hs-cTnT < limit of detection (< 5 ng/L) strategy, HEART pathway, and EDACS-ADP was evaluated on Rule-out of index visit NSTEMI at 0 hours (proportion ruled out and negative predictive value) (ARR 18.2%, 95% CI 17.4-19.1). The HEAR pathway ruled out index NSTEMI in 21.0% of chest pain patients with 100.0% NPV (95% CI 99.8-100.0%), reducing second troponin tests by 18.2% (95% CI 17.4-19.1%) vs the LoD strategy.

synapsesocial.com/papers/6a776c3e1400807f0f1eaa10 https://doi.org/10.3390/diagnostics13203217

View Full Paper

Ask AI

Bookmark

Share

Derivation of a HEAR Pathway for Emergency Department Chest Pain Patients to Safely Avoid a Second Troponin Test

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Derivation of a HEAR Pathway for Emergency Department Chest Pain Patients to Safely Avoid a Second Troponin Test

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Keep reading

Keep reading