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Coronary artery disease
Original research
Comparison of accelerated diagnostic pathways for acute chest pain risk stratification
  1. Jason Stopyra1,
  2. Anna Catherine Snavely2,
  3. Brian Hiestand1,
  4. Brian J Wells3,
  5. Kristin Macfarlane Lenoir2,
  6. David Herrington4,
  7. Nella Hendley1,
  8. Nicklaus P Ashburn1,
  9. Chadwick D Miller1,
  10. Simon A Mahler1
  1. 1 Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
  2. 2 Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
  3. 3 Translational Science Institute, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
  4. 4 Division of Cardiovascular Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
  1. Correspondence to Dr Jason Stopyra, Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA; jstopyra{at}wakehealth.edu

Abstract

Background The History Electrocardiogram Age Risk factor Troponin (HEART) Pathway and Emergency Department Assessment of Chest pain Score (EDACS) are validated accelerated diagnostic pathways designed to risk stratify patients presenting to the emergency department with chest pain. Data from large multisite prospective studies comparing these accelerated diagnostic pathways are limited.

Methods The HEART Pathway Implementation is a prospective three-site cohort study, which accrued adults with symptoms concerning for acute coronary syndrome. Physicians completed electronic health record HEART Pathway and EDACS risk assessments on participants. Major adverse cardiac events (death, myocardial infarction and coronary revascularisation) at 30 days were determined using electronic health record, insurance claims and death index data. Test characteristics for detection of major adverse cardiac events were calculated for both accelerated diagnostic pathways and McNemar’s tests were used for comparisons.

Results 5799 patients presenting to the emergency department were accrued, of which HEART Pathway and EDACS assessments were completed on 4399. Major adverse cardiac events at 30 days occurred in 449/4399 (10.2%). The HEART Pathway identified 38.4% (95% CI 37.0% to 39.9%) of patients as low-risk compared with 58.1% (95% CI 56.6% to 59.6%) identified as low-risk by EDACS (p<0.001). Major adverse cardiac events occurred in 0.4% (95% CI 0.2% to 0.9%) of patients classified as low-risk by the HEART Pathway compared with 1.0% (95% CI 0.7% to 1.5%) of patients identified as low-risk by EDACS (p<0.001). Thus, the HEART Pathway had a negative predictive value of 99.6% (95% CI 99.1% to 99.8%) for major adverse cardiac events compared with a negative predictive value of 99.0% (95% CI 98.5% to 99.3%) for EDACS.

Conclusions EDACS identifies a larger proportion of patients as low-risk than the HEART Pathway, but has a higher missed major adverse cardiac events rate at 30 days. Physicians will need to consider their risk tolerance when deciding whether to adopt the HEART Pathway or EDACS accelerated diagnostic pathway.

Trial registration number NCT02056964.

  • acute coronary syndromes
  • healthcare delivery

https://doi.org/10.1136/heartjnl-2019-316426

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    Footnotes

    • Twitter @Nick_Ashburn1

    • Contributors All authors contributed to the planning, conduct and reporting of the work described in this article. JS and SAM are responsible for the overall content as guarantors.

    • Funding The HEART Pathway Implementation Study was funded by the Donaghue Foundation.

    • Competing interests SM also receives research funding/support from Abbott Point of Care, Roche Diagnostics, Siemens, PCORI and NHLBI (1 R01 HL118263-01, L30 HL120008). SM is the Chief Medical Officer for Impathiq Inc. JS receives research funding/support from Abbott Point of Care, Roche Diagnostics and and NHLBI (1 R01 HL118263-01). CM receives research funding/support from Siemens, Abbott Point of Care and 1 R01 HL118263. ACS receives research funding from NHLBI (1 R01 HL118263-01).

    • Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

    • Patient consent for publication Not required.

    • Ethics approval This study was approved by the Institutional Review Board of the sponsoring organisation.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data are available on reasonable request. Data that support the findings of this study are available on request from the corresponding author (http://orcid.org/0000-0001-7457-3969). The data are not publicly available due to information that could compromise the identity of research participants.

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