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Performance analysis considering endpoints for three accelerated diagnostic protocols for chest pain
Bora Chae1, Shin Ahn1, Seung Mok Ryoo1
1Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
Insights
Three accelerated diagnostic protocols (ADPs) for chest pain assessment showed high sensitivity for major adverse cardiac events (MACE) excluding unstable angina. However, their safety levels decreased when unstable angina was included in MACE.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Diagnostics
Background:
- Accelerated diagnostic protocols (ADPs) like mADAPT, HEART pathway, and EDACS-ADP are crucial for assessing chest pain patients.
- These protocols typically define Major Adverse Cardiac Events (MACE) as acute myocardial infarction, revascularization, and death, excluding unstable angina.
Purpose of the Study:
- To compare the performance of three well-known ADPs (mADAPT, HEART pathway, EDACS-ADP) in evaluating patients with chest pain.
- To assess the diagnostic accuracy of these ADPs for 30-day MACE, both with and without the inclusion of unstable angina.
Main Methods:
- A single-center prospective observational study was conducted.
- The study included 1,214 patients presenting with chest pain symptoms.
- Performance comparison of mADAPT, HEART pathway, and EDACS-ADP was performed for MACE, with and without unstable angina.
Main Results:
- When unstable angina was excluded, sensitivities for MACE were high (>99%) for all three ADPs.
- The HEART pathway identified the highest proportion of low-risk patients (39.2%).
- When unstable angina was included in MACE, sensitivities dropped below 99% for all ADPs (mADAPT: 96.6%, EDACS-ADP: 97.3%, HEART pathway: 97.3%).
Conclusions:
- All three ADPs demonstrated similar accuracy for MACE risk stratification when unstable angina was excluded.
- The HEART pathway offered the best balance of sensitivity and early discharge potential.
- Inclusion of unstable angina in MACE significantly reduced the safety and performance of all evaluated ADPs below acceptable thresholds.
Introduction:
The modified accelerated diagnostic protocol (ADP) to assess patients with chest pain symptoms using troponin as the only biomarker (mADAPT), the History, ECG, Age, Risk factors, and Troponin (HEART) pathway, and the Emergency Department Assessment of Chest Pain Rule (EDACS)-ADP, are the three most well-known ADPs for patients with chest pain. These ADPs define major adverse cardiac event (MACE) as components of acute myocardial infarction, revascularization, and death; unstable angina is not included as an endpoint.
Methods:
We performed a single-center prospective observational study comparing the performance of these 3 ADPs for patients with 30-day MACE with and without unstable angina. We hypothesized that these ADPs will have high sensitivities for MACE without unstable angina, a definition used for score derivation studies. However, when unstable angina is included in the MACE, their performances would be lower than the acceptable rate of >99% sensitivity.
Results:
A total of 1,214 patients were included in the analysis. When unstable angina was not included in the endpoint, sensitivities for MACE were 99.1% (95% confidence interval [CI]: 96.7-99.9%), 99.5% (95% CI: 97.4-100%), and 100% (95% CI: 98.3-100%) for mADAPT, EDACS-ADP, and HEART pathway, respectively. The HEART pathway had the highest proportion of patients classified as low risk (39.2%, 95% CI: 35.8-42.9%), followed by EDACS-ADP (31.3%, 95% CI: 28.2-34.6%) and mADAPT (29.3%, 95% CI: 26.4-32.5%). However, when unstable angina was included in the MACE, sensitivities were 96.6% (95% CI: 94.4-98.1%) for mADAPT, 97.3% (95% CI: 95.3-98.6%) for EDACS-ADP, and 97.3% (95% CI: 95.3-98.6%) for the HEART pathway, respectively. There were 15 false-negative cases with mADAPT, and 12 false-negative cases each for EDACS-ADP and HEART pathway.
Conclusion:
All three ADPs-mADAPT, EDACS-ADP, and HEART pathway-were similarly accurate in their discriminatory performance for the risk stratification of ED patients presenting with possible ACS when unstable angina was not included in the endpoint. The HEART pathway showed the best combination of sensitivity and proportion of patients that can be classified as safe for early discharge. However, when unstable angina was added to the endpoint, all three ADPs did not show appropriate safety levels and their performances were lower than the acceptable risk of MACE.
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