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Performance of the High-STEACS Early Rule Out Pathway Using hs-cTnT at 30 Days in a Multisite US Cohort
Nicklaus P Ashburn1, Anna C Snavely1,2, Michael W Supples1
1Department of Emergency Medicine (N.P.A., A.C.S., M.W.S., M.J.M., T.H., S.A.M.), Wake Forest University School of Medicine, Winston-Salem, NC.
Insights
The High-STEACS pathway effectively identifies patients for outpatient care but did not meet the 99% safety threshold for 30-day cardiac death or myocardial infarction. Further refinement is needed for high-risk patients.
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.
Background:
The High-STEACS (High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome) pathway risk stratifies emergency department patients with possible acute coronary syndrome. This study aims to determine if the High-STEACS hs-cTnT (high-sensitivity cardiac troponin T) pathway can achieve the ≥99% negative predictive value (NPV) safety threshold for 30-day cardiac death or myocardial infarction (CDMI) in a multisite US cohort of patients with and without known coronary artery disease (CAD).
Methods:
A secondary analysis of the STOP-CP (High-Sensitivity Cardiac Troponin T [Gen 5 STAT Assay] to Optimize Chest Pain Risk Stratification) cohort, which enrolled adult emergency department patients with possible acute coronary syndrome at 8 US sites (January 25, 2017-September 6, 2018). Participants were classified into outpatient and admission dispositions using the High-STEACS hs-cTnT pathway. Known CAD was defined as prior MI, coronary revascularization, or ≥70% coronary stenosis. Outcomes included 30-day CDMI and efficacy, defined as the proportion identified for outpatient disposition. NPVs and negative likelihood ratios for 30-day CDMI were calculated. NPVs were compared between CAD subgroups using a Fisher exact test.
Results:
Among 1351 patients, 53.2% (719/1351) were male, 31.4% (424/1351) had known CAD, and the mean age was 57.4±12.8 years. At 30 days, CDMI occurred in 13.8% (187/1351). High-STEACS classified 63.4% (857/1351) to outpatient disposition, of which 2.0% (17/857) had 30-day CDMI, corresponding to an NPV of 98.0% (95% CI, 96.8-98.8) and negative likelihood ratio of 0.13 (95% CI, 0.08-0.20). In patients with CAD, 46.9% (199/424) were classified to outpatient disposition, of which 4.0% (8/199) had 30-day CDMI. Among patients without CAD, 71.0% (658/927) were classified to outpatient disposition with 1.4% (9/658) having 30-day CDMI. The NPV for 30-day CDMI was 96.0% (95% CI, 92.2-98.2) in patients with CAD versus 98.6% (95% CI, 97.4-99.4) among patients without CAD (P=0.04). The negative likelihood ratio for 30-day CDMI among patients with CAD was 0.16 (95% CI, 0.08-0.31) and 0.12 (95% CI, 0.06-0.22) among patients without CAD.
Conclusions:
The High-STEACS hs-cTnT pathway had high efficacy but was unable to achieve the ≥99% NPV safety threshold for 30-day CDMI.
Registration:
URL: https://www.clinicaltrials.gov; Unique identifier: NCT02984436.
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