Derivation of a HEAR Pathway for Emergency Department Chest Pain Patients to Safely Avoid a Second Troponin Test
Chen Chen1, Yao Yu1, Dongxu Chen1
1Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China.
Insights
A new HEAR score pathway using history, ECG, age, and risk factors, combined with initial troponin T levels, can safely reduce the need for repeat troponin tests in suspected myocardial infarction cases.
Area of Science:
- Cardiology
- Emergency Medicine
- Diagnostic Testing
Background:
- Suspected non-ST elevation myocardial infarction (NSTEMI) diagnosis in emergency departments often requires serial troponin testing.
- This approach increases healthcare costs and patient wait times.
- Developing efficient, safe diagnostic strategies is crucial.
Purpose of the Study:
- To develop and validate a decision pathway using the HEAR score and baseline high-sensitivity cardiac troponin T (hs-cTnT) to safely rule out NSTEMI.
- To reduce the need for a second troponin test in emergency department patients.
Main Methods:
- Retrospective analysis of 7131 patients with suspected NSTEMI.
- Development of a HEAR pathway (History, ECG, Age, Risk factors) using a Bayesian approach.
- Evaluation of the pathway's performance against index visit NSTEMI and 180-day major adverse cardiovascular events (MACE).
Main Results:
- The HEAR pathway demonstrated a 100.0% negative predictive value for index visit NSTEMI.
- The false-negative rate for 180-day MACE was 0.40%.
- The HEAR pathway reduced the need for a second troponin test by 18.2% compared to a <5 ng/L hs-cTnT strategy.
Conclusions:
- The HEAR pathway, integrating clinical data and initial hs-cTnT, offers a safe and effective method to avoid serial troponin testing in suspected NSTEMI.
- This strategy can significantly decrease diagnostic workload and improve emergency department efficiency.
Abstract:
The study aims to develop a decision pathway based on HEAR score and 0 h high-sensitivity cardiac troponin T (hs-cTnT) to safely avoid a second troponin test for suspected non-ST elevation myocardial infarction (NSTEMI) in emergency departments. A HEAR score consists of history, electrocardiogram, age, and risk factors. A HEAR pathway is established using a Bayesian approach based on a predefined safety threshold of NSTEMI prevalence in the rule-out group. In total, 7131 patients were retrospectively enrolled, 582 (8.2%) with index visit NSTEMI and 940 (13.2%) with 180-day major adverse cardiovascular events (MACE). For patients with a low-risk HEAR score (0 to 2) and low 0 h hs-cTnT (<14 ng/L), the HEAR pathway recommends early discharge without further testing. After the HEAR pathway had been applied to rule out NSTEMI, the negative predictive value of index visit NSTEMI was 100.0% (95% CI, 99.8% to 100.0%) and false-negative rate of 180-day MACE was 0.40% (95% CI, 0.18% to 0.87%). Compared with the 0 h hs-cTnT < limit of detection (LoD) strategy (<5 ng/L), the HEAR pathway could correctly reclassify 1298 patients without MACE as low risk and lead to a 18.2% decrease (95% CI, 17.4-19.1%) in the need for a second troponin test. The HEAR pathway may lead to a substantial and safe reduction in repeated troponin test for emergency department patients with suspected NSTEMI.
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