Why the study?
The comparative accuracy of the EDACS and modified HEART risk scores using cardiac troponin I cutoffs below the 99th percentile for predicting low risk of MACE was uncertain.
Do the modified HEART and EDACS risk scores accurately identify emergency department patients with possible ACS at low risk for 60-day MACE when using a cTnI cutoff below the 99th percentile?
Cohort (n=118,822)
Do the modified HEART and EDACS risk scores accurately identify emergency department patients with possible ACS at low risk for 60-day MACE when using a cTnI cutoff below the 99th percentile?
p-value: p=0.27
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Now we're looking at 50% to 60% of [our] population having a low enough risk that no further testing is warranted. Specifically to that point, the EDACS had a larger proportion of patients that fell in that category than did the HEART, so it would appear to be more specific without a loss of sensitivity.”
“With rising costs and increasing pressure to reduce hospitalizations, a clear tension is present; on the one hand, we cannot admit every patient to evaluate chest discomfort, but on the other hand, missing a high-risk cardiac diagnosis is not acceptable. With several available clinical risk scores with significant ability to exclude MI while simultaneously identifying substantial numbers of lower-risk patients suitable for early discharge, we may finally have a suitable gatekeeper to assist the pressurized decision-making that occurs in the ED setting.”
“This evidence will help Kaiser Permanente emergency physicians accurately identify patients with chest pain who are at very low risk and or higher levels of risk for major cardiac events, so that patients at lower risk can potentially avoid unnecessary workups.”
When assessing patients with possible ACS in the emergency department, using a troponin cutoff below the 99th percentile in conjunction with the original EDACS score safely maximizes the identification of low-risk patients.
BACKGROUND: Both the modified History, Electrocardiogram, Age, Risk factors and Troponin (HEART) score and the Emergency Department Assessment of Chest pain Score (EDACS) can identify patients with possible acute coronary syndrome (ACS) at low risk (<1%) for major adverse cardiac events (MACE). OBJECTIVES: The authors sought to assess the comparative accuracy of the EDACS (original and simplified) and modified HEART risk scores when using cardiac troponin I (cTnI) cutoffs below the 99th percentile, and obtain precise MACE risk estimates. METHODS: The authors conducted a retrospective study of adult emergency department (ED) patients evaluated for possible ACS in an integrated health care system between 2013 and 2015. Negative predictive values for MACE (composite of myocardial infarction, cardiogenic shock, cardiac arrest, and all-cause mortality) were determined at 60 days. Reclassification analyses were used to assess the comparative accuracy of risk scores and lower cTnI cutoffs. RESULTS: A total of 118,822 patients with possible ACS were included. The 3 risk scores' accuracies were optimized using the lower limit of cTnI quantitation (<0.02 ng/ml) to define low risk for 60-day MACE, with reclassification yields ranging between 3.4% and 3.9%, while maintaining similar negative predictive values (range 99.49% to 99.55%; p = 0.27). The original EDACS identified the largest proportion of patients as low risk (60.6%; p < 0.0001). CONCLUSIONS: Among ED patients with possible ACS, the modified HEART score, original EDACS, and simplified EDACS all predicted a low risk of 60-day MACE with improved accuracy using a cTnI cutoff below the 99th percentile. The original EDACS identified the most low-risk patients, and thus may be the preferred risk score.
No takes yet. Share an insight, caveat, or question.
Mark et al. (2018) conducted a cohort in Possible acute coronary syndrome (ACS) (n=118,822). Original EDACS (Emergency Department Assessment of Chest pain Score) vs. Modified HEART score and simplified EDACS was evaluated on Negative predictive value for 60-day MACE (composite of myocardial infarction, cardiogenic shock, cardiac arrest, and all-cause mortality) (p=0.27).
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: