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Graded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort Study
Dustin G Mark1,2,3, Jie Huang3, Dustin W Ballard3,4
1Department of Emergency Medicine Kaiser Permanente Oakland Medical Center Oakland CA.
Insights
The RISTRA-ACS algorithm improved cardiac testing allocation for chest pain patients in emergency departments. It optimized testing without increasing resource use or major adverse cardiac events.
Area of Science:
- Emergency Medicine
- Cardiology
- Health Services Research
Background:
- Emergency department (ED) resource utilization for chest pain is highly variable.
- Acute coronary syndrome (ACS) risk stratification is crucial for appropriate patient management.
- Existing risk assessment tools may not optimally guide diagnostic testing.
Purpose of the Study:
- To evaluate the impact of implementing a graded coronary risk stratification algorithm (RISTRA-ACS) on resource utilization and patient outcomes.
- To assess the algorithm's effect on objective cardiac testing and major adverse cardiac events (MACE).
Main Methods:
- Controlled cohort study across 21 EDs in an integrated healthcare system.
- Implementation of RISTRA-ACS in 13 EDs (RISTRA sites) versus 8 control EDs over 48 months.
- Difference-in-differences analysis of 154,914 patient encounters with chest pain and troponin measurement.
Main Results:
- RISTRA-ACS implementation led to decreased 30-day cardiac testing in low-risk patients (≤2% MACE risk) and increased testing in higher-risk patients (>2% MACE risk).
- No significant differences were observed in index visit resource utilization (admission, observation, or 7-day testing).
- No statistically significant differences in 60-day MACE or MACE-CR (MACE excluding revascularization) were found.
Conclusions:
- RISTRA-ACS effectively improved the allocation of 30-day objective cardiac testing for emergency department chest pain patients.
- The algorithm demonstrated no adverse impact on immediate resource utilization or 60-day major adverse cardiac events.
- RISTRA-ACS offers a valuable tool for optimizing diagnostic pathways in suspected acute coronary syndrome.
Abstract:
Background Resource utilization among emergency department (ED) patients with possible coronary chest pain is highly variable. Methods and Results Controlled cohort study amongst 21 EDs of an integrated healthcare system examining the implementation of a graded coronary risk stratification algorithm (RISTRA-ACS [risk stratification for acute coronary syndrome]). Thirteen EDs had access to RISTRA-ACS within the electronic health record (RISTRA sites) beginning in month 24 of a 48-month study period (January 2016 to December 2019); the remaining 8 EDs served as contemporaneous controls. Study participants had a chief complaint of chest pain and serum troponin measurement in the ED. The primary outcome was index visit resource utilization (observation unit or hospital admission, or 7-day objective cardiac testing). Secondary outcomes were 30-day objective cardiac testing, 60-day major adverse cardiac events (MACE), and 60-day MACE-CR (MACE excluding coronary revascularization). Difference-in-differences analyses controlled for secular trends with stratification by estimated risk and adjustment for risk factors, ED physician and facility. A total of 154 914 encounters were included. Relative to control sites, 30-day objective cardiac testing decreased at RISTRA sites among patients with low (≤2%) estimated 60-day MACE risk (-2.5%, 95% CI -3.7 to -1.2%, P<0.001) and increased among patients with non-low (>2%) estimated risk (+2.8%, 95% CI +0.6 to +4.9%, P=0.014), without significant overall change (-1.0%, 95% CI -2.1 to 0.1%, P=0.079). There were no statistically significant differences in index visit resource utilization, 60-day MACE or 60-day MACE-CR. Conclusions Implementation of RISTRA-ACS was associated with better allocation of 30-day objective cardiac testing and no change in index visit resource utilization or 60-day MACE. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03286179.
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