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Validation of the ACC Expert Consensus Decision Pathway for Patients With Chest Pain
Simon A Mahler1, Nicklaus P Ashburn2, Michael W Supples2
1Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA; Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA; Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
Insights
The American College of Cardiology (ACC) chest pain pathway is safe and effective for most patients. However, its safety is questionable for individuals with known coronary artery disease (CAD).
Area of Science:
- Cardiology
- Clinical Pathways
- Emergency Medicine
Background:
- The American College of Cardiology (ACC) developed an Expert Consensus Decision Pathway for managing chest pain.
- This pathway provides a standardized approach to diagnosing and treating patients presenting with chest pain.
Purpose of the Study:
- To validate the clinical utility and safety of the ACC Expert Consensus Decision Pathway for chest pain.
- To assess the pathway's performance in a real-world, multi-site U.S. emergency department setting.
Main Methods:
- An observational cohort study included 14,395 adults with suspected acute coronary syndrome across 5 U.S. emergency departments.
- Electrocardiograms (ECGs) and serial high-sensitivity troponin measurements were used for risk stratification according to the ACC Pathway.
- The primary safety endpoint was 30-day all-cause death or myocardial infarction (MI); efficacy was measured by the proportion stratified to the rule-out zone.
Main Results:
- The ACC Pathway demonstrated an overall efficacy of 48.1%.
- In the overall cohort, the pathway achieved a high negative predictive value of 99.7% for 30-day death or MI.
- However, among patients with known coronary artery disease (CAD), 1.5% experienced death or MI despite being stratified to the rule-out zone.
Conclusions:
- The ACC Expert Consensus Decision Pathway for chest pain is generally safe and effective.
- Caution is advised when applying the pathway to patients with a history of known coronary artery disease due to potential safety concerns.
Background:
The American College of Cardiology (ACC) recently published an Expert Consensus Decision Pathway for chest pain.
Objectives:
The purpose of this study was to validate the ACC Pathway in a multisite U.S.
Methods:
An observational cohort study of adults with possible acute coronary syndrome was conducted. Patients were accrued from 5 U.S. Emergency Departments (November 1, 2020, to July 31, 2022). ECGs and 0- and 2-hour high-sensitivity troponin (Beckman Coulter) measures were used to stratify patients according to the ACC Pathway. The primary safety outcome was 30-day all-cause death or myocardial infarction (MI). Efficacy was defined as the proportion stratified to the rule-out zone. Negative predictive value for 30-day death or MI was assessed among the whole cohort and in a subgroup of patients with coronary artery disease (CAD) (prior MI, revascularization, or ≥70% coronary stenosis).
Results:
ACC Pathway assessments were complete in 14,395 patients, of whom 51.7% (7,437 of 14,395) were women with a median age of 56 years (Q1-Q3: 44-68 years). Known CAD was present in 23.5% (3,386 of 14,395) and 30-day death or MI occurred in 8.1% (1,168 of 14,395). The ACC Pathway had an efficacy of 48.1% (95% CI: 47.3%-49.0%). Among patients in the rule-out zone, 0.3% (22 of 6,930) had death or MI at 30 days, yielding a negative predictive value of 99.7% (95% CI: 99.5%-99.8%). In patients with known CAD, 20.0% (676 of 3,386) were classified to the rule-out zone, of whom 1.5% (10 of 676) had death or MI.
Conclusions:
The ACC expert consensus decision pathway was safe and efficacious. However, it may not be safe for use among patients with known CAD.
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