Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter?
Henderson D McGinnis1, Nicklaus P Ashburn1, Brennan E Paradee1
1Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.
Insights
Moderate-risk patients with acute coronary syndrome (ACS) have low major adverse cardiac event (MACE) rates. However, prior coronary artery disease (CAD) significantly increases MACE risk in these patients.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Research
Background:
- Many patients with negative troponins and non-ischemic electrocardiograms (ECGs) are admitted for possible acute coronary syndrome (ACS).
- Risk stratification is crucial for appropriate patient management and resource allocation in emergency departments.
Purpose of the Study:
- To determine the rate of major adverse cardiac events (MACE) in moderate-risk patients presenting with possible ACS.
- To investigate how a history of coronary artery disease (CAD) influences MACE rates in this patient group.
Main Methods:
- A secondary analysis of the HEART Pathway implementation study involving adults with possible ACS.
- Moderate-risk patients were identified using the HEAR score (≥4), negative troponins, and non-ischemic ECGs, excluding low-risk individuals.
- MACE (death, myocardial infarction, revascularization) at 30 days was assessed and compared between moderate-risk patients with and without prior CAD.
Main Results:
- Of 4,550 patients assessed, 37.7% were moderate risk. Overall 30-day MACE rate in moderate-risk patients was 3.1%.
- Moderate-risk patients with prior CAD had a significantly higher MACE rate (7.1%) compared to those without prior CAD (1.4%).
- The negative likelihood ratio for 30-day MACE in moderate-risk patients without prior CAD was low (0.08).
Conclusions:
- Thirty-day MACE rates are low in moderate-risk patients with possible ACS.
- A history of prior coronary artery disease is a significant predictor of increased MACE in moderate-risk patients.
- These findings support refined risk stratification strategies for patients with possible ACS.
Background:
Despite negative troponins and nonischemic electrocardiograms (ECGs), patients at moderate risk for acute coronary syndrome (ACS) are frequently admitted. The objective of this study was to describe the major adverse cardiac event (MACE) rate in moderate-risk patients and how it differs based on history of coronary artery disease (CAD).
Methods:
A secondary analysis of the HEART Pathway implementation study was conducted. This prospective interrupted time-series study accrued adults with possible ACS from three sites (November 2013-January 2016). This analysis excluded low-risk patients determined by emergency providers' HEART Pathway assessments. Non-low-risk patients were further classified as high risk, based on elevated troponin measures or ischemic ECG findings or as moderate risk, based on HEAR score ≥ 4, negative troponin measures, and a nonischemic ECG. Moderate-risk patients were then stratified by the presence or absence of prior CAD (MI, revascularization, or ≥70% coronary stenosis). MACE (death, myocardial infarction, or revascularization) at 30 days was determined from health records, insurance claims, and death index data. MACE rates were compared among groups using a chi-square test and likelihood ratios (LRs) were calculated.
Results:
Among 4,550 patients with HEART Pathway assessments, 24.8% (1,130/4,550) were high risk and 37.7% (1715/4550) were moderate risk. MACE at 30 days occurred in 3.1% (53/1,715; 95% confidence interval [CI] = 2.3% to 4.0%) of moderate-risk patients. Among moderate-risk patients, MACE occurred in 7.1% (36/508, 95% CI = 5.1% to 9.8%) of patients with known CAD versus 1.4% (17/1,207, 95% CI = 0.9% to 2.3%) in patients without known prior CAD (p < 0.0001). The negative LR for 30-day MACE among moderate-risk patients without prior CAD was 0.08 (95% CI = 0.05 to 0.12).
Conclusion:
MACE rates at 30 days were low among moderate-risk patients but were significantly higher among those with prior CAD.
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