Stopyra Jason, Snavely Anna Catherine, Hiestand Brian, Wells Brian J, Lenoir Kristin Macfarlane, Herrington David, Hendley Nella, Ashburn Nicklaus P, Miller Chadwick D, Mahler Simon A
Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
Heart. 2020 Jul;106(13):977-984. doi: 10.1136/heartjnl-2019-316426. Epub 2020 Apr 8.
The History Electrocardiogram Age Risk factor Troponin (HEART) Pathway and Emergency Department Assessment of Chest pain Score (EDACS) are validated accelerated diagnostic pathways designed to risk stratify patients presenting to the emergency department with chest pain. Data from large multisite prospective studies comparing these accelerated diagnostic pathways are limited.
The HEART Pathway Implementation is a prospective three-site cohort study, which accrued adults with symptoms concerning for acute coronary syndrome. Physicians completed electronic health record HEART Pathway and EDACS risk assessments on participants. Major adverse cardiac events (death, myocardial infarction and coronary revascularisation) at 30 days were determined using electronic health record, insurance claims and death index data. Test characteristics for detection of major adverse cardiac events were calculated for both accelerated diagnostic pathways and McNemar's tests were used for comparisons.
5799 patients presenting to the emergency department were accrued, of which HEART Pathway and EDACS assessments were completed on 4399. Major adverse cardiac events at 30 days occurred in 449/4399 (10.2%). The HEART Pathway identified 38.4% (95% CI 37.0% to 39.9%) of patients as low-risk compared with 58.1% (95% CI 56.6% to 59.6%) identified as low-risk by EDACS (p<0.001). Major adverse cardiac events occurred in 0.4% (95% CI 0.2% to 0.9%) of patients classified as low-risk by the HEART Pathway compared with 1.0% (95% CI 0.7% to 1.5%) of patients identified as low-risk by EDACS (p<0.001). Thus, the HEART Pathway had a negative predictive value of 99.6% (95% CI 99.1% to 99.8%) for major adverse cardiac events compared with a negative predictive value of 99.0% (95% CI 98.5% to 99.3%) for EDACS.
EDACS identifies a larger proportion of patients as low-risk than the HEART Pathway, but has a higher missed major adverse cardiac events rate at 30 days. Physicians will need to consider their risk tolerance when deciding whether to adopt the HEART Pathway or EDACS accelerated diagnostic pathway.
NCT02056964.
病史心电图年龄风险因素肌钙蛋白（HEART）路径和急诊科胸痛评估评分（EDACS）是经过验证的加速诊断路径，旨在对因胸痛就诊于急诊科的患者进行风险分层。来自大型多中心前瞻性研究比较这些加速诊断路径的数据有限。
HEART路径实施是一项前瞻性三中心队列研究，纳入有急性冠状动脉综合征相关症状的成年人。医生对参与者完成电子健康记录HEART路径和EDACS风险评估。使用电子健康记录、保险理赔和死亡指数数据确定30天时的主要不良心脏事件（死亡、心肌梗死和冠状动脉血运重建）。计算两种加速诊断路径检测主要不良心脏事件的检验特征，并使用McNemar检验进行比较。
共纳入5799例就诊于急诊科的患者，其中4399例完成了HEART路径和EDACS评估。449/4399（10.2%）例患者在30天时发生主要不良心脏事件。HEART路径将38.4%（95%CI 37.0%至39.9%）的患者识别为低风险，而EDACS识别为低风险的患者比例为58.1%（95%CI 56.6%至59.6%）（p<0.001）。HEART路径分类为低风险的患者中，0.4%（95%CI 0.2%至0.9%）发生主要不良心脏事件，而EDACS识别为低风险的患者中这一比例为1.0%（95%CI 0.7%至1.5%）（p<0.001）。因此，HEART路径对主要不良心脏事件的阴性预测值为99.6%（95%CI 99.1%至99.8%），而EDACS的阴性预测值为99.0%（95%CI 98.5%至99.3%）。
与HEART路径相比，EDACS识别出的低风险患者比例更大，但30天时主要不良心脏事件的漏诊率更高。医生在决定采用HEART路径还是EDACS加速诊断路径时需要考虑其风险承受能力。
NCT02056964。
