Performance of the High-STEACS Early Rule Out Pathway Using hs-cTnT at 30 Days in a Multisite US Cohort

Area of Science:

• Cardiology
• Emergency Medicine
• Diagnostic Pathways

Background:

• Acute coronary syndrome (ACS) requires accurate risk stratification in emergency departments.
• The High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome (High-STEACS) pathway uses high-sensitivity cardiac troponin T (hs-cTnT) for risk assessment.
• Evaluating the safety and efficacy of novel diagnostic pathways is crucial for patient outcomes.

Purpose of the Study:

• To determine if the High-STEACS hs-cTnT pathway achieves a ≥99% negative predictive value (NPV) for 30-day cardiac death or myocardial infarction (CDMI).
• To assess the pathway's performance in a diverse US cohort, including patients with and without known coronary artery disease (CAD).
• To evaluate the pathway's efficacy in classifying patients for outpatient disposition.

Main Methods:

• Secondary analysis of the STOP-CP cohort (n=1351) from 8 US emergency departments.
• Patients with possible ACS were classified using the High-STEACS hs-cTnT pathway.
• Outcomes (30-day CDMI) and disposition efficacy were analyzed, with NPVs compared between CAD subgroups.

Main Results:

• The High-STEACS pathway classified 63.4% of patients for outpatient disposition with a 98.0% NPV for 30-day CDMI.
• Patients with known CAD had a lower NPV (96.0%) compared to those without CAD (98.6%).
• The pathway demonstrated high efficacy but did not meet the ≥99% NPV safety threshold.

Conclusions:

• The High-STEACS hs-cTnT pathway shows high efficacy in risk stratification for possible ACS.
• The pathway did not achieve the target ≥99% NPV for 30-day CDMI, particularly in patients with known CAD.
• Further optimization of the High-STEACS pathway may be necessary to meet stringent safety criteria.