Derivation and validation of a high sensitivity troponin-T HEART pathway
Anna C Snavely1, Brennan E Paradee2, Nicklaus P Ashburn2
1Department of Biostatistics and Data Science, Wake Forest School of Medicine (WFSOM), Winston-Salem, NC; Department of Emergency Medicine, WFSOM, Winston Salem, NC.
Insights
A new HEART Pathway using high-sensitivity troponin T (hs-cTnT) effectively identifies patients with chest pain who are at low risk for cardiac events. This optimized pathway improves risk stratification for 30-day cardiac death or myocardial infarction.
Area of Science:
- Cardiology
- Emergency Medicine
- Biomarkers
Background:
- The HEART Pathway is a standard tool for chest pain risk stratification.
- Existing protocols require optimization for high-sensitivity troponin T (hs-cTnT) assays.
Purpose of the Study:
- To derive and validate an optimized HEART Pathway incorporating serial hs-cTnT measurements.
- To improve the accuracy of risk stratification for 30-day cardiac death or myocardial infarction (MI).
Main Methods:
- Secondary analysis of the prospective STOP-CP cohort study (n=1452) including adult emergency department patients.
- Development of a hs-cTnT HEART Pathway using a derivation cohort (n=729) with optimal troponin cutoffs and 0-1 hour delta values.
- Validation of the pathway's performance in a separate validation cohort (n=723).
Main Results:
- The optimized hs-cTnT HEART Pathway achieved a negative predictive value (NPV) >99% for ruling out 30-day cardiac death or MI in both derivation (99.2%) and validation (99.3%) cohorts.
- The pathway classified 36.5% (derivation) and 37.6% (validation) of patients into the rule-out group.
- The rule-in group had a positive predictive value (PPV) of 55.4% (derivation) and 57.1% (validation).
Conclusions:
- A novel hs-cTnT HEART Pathway utilizing serial hs-cTnT measurements demonstrates high NPV for 30-day cardiac death or MI.
- This optimized pathway offers improved risk stratification for patients presenting with chest pain.
- The pathway provides a reliable method for ruling out acute coronary syndromes in the emergency department.
Background:
The HEART Pathway is widely used for chest pain risk stratification but has yet to be optimized for high sensitivity troponin T (hs-cTnT) assays.
Methods:
We conducted a secondary analysis of STOP-CP, a prospective cohort study enrolling adult ED patients with symptoms suggestive of acute coronary syndrome at 8 sites in the United States (US). Patients had a 0- and 1-hour hs-cTnT measured and a HEAR score completed. A derivation set consisting of 729 randomly selected participants was used to derive a hs-cTnT HEART Pathway with rule-out, observation, and rule-in groups for 30-day cardiac death or myocardial infarction (MI). Optimal baseline and 1-hour troponin cutoffs were selected using generalized cross validation to achieve a negative predictive value (NPV) >99% for rule out and positive predictive value (PPV) >60% or maximum Youden index for rule-in. Optimal 0-1-hour delta values were derived using generalized cross validation to maximize the NPV for the rule-out group and PPV for the rule-in group. The hs-cTnT HEART Pathway performance was validated in the remaining cohort (n = 723).
Results:
Among the 1452 patients, 30-day cardiac death or MI occurred in 12.7% (184/1452). Within the derivation cohort the optimal hs-cTnT HEART Pathway classified 36.5% (266/729) into the rule-out group, yielding a NPV of 99.2% (95% CI: 98.2-100) for 30-day cardiac death or MI. The rule-in group included 15.4% (112/729) with a PPV of 55.4% (95% CI: 46.2-64.6). In the validation cohort, the hs-cTnT HEART Pathway ruled-out 37.6% (272/723), of which 2 had 30-day cardiac death or MI, yielding a NPV of 99.3% (95% CI: 98.3-100). The rule-in group included 14.5% (105/723), yielding a PPV of 57.1% (95% CI: 47.7-66.6).
Conclusions:
A novel hs-cTnT HEART Pathway with serial 0- and 1-hour hs-cTnT measures has high NPV and moderate PPV for 30-day cardiac death or MI.
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