Chen Chen, Yu Yao, Chen Dongxu, Cai Canguang, Zhou Yannan, Liao Fengqing, Humarbek Alima, Li Xuan, Song Zhenju, Sun Zhan, Tong Chaoyang, Yao Chenling, Gu Guorong
Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, China.
Diagnostics (Basel). 2023 Oct 16;13(20):3217. doi: 10.3390/diagnostics13203217.
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.
本研究旨在基于HEAR评分和0小时高敏心肌肌钙蛋白T（hs-cTnT）制定一条决策路径，以在急诊科安全地避免对疑似非ST段抬高型心肌梗死（NSTEMI）患者进行二次肌钙蛋白检测。HEAR评分由病史、心电图、年龄和危险因素组成。基于排除组中NSTEMI患病率的预定义安全阈值，采用贝叶斯方法建立HEAR路径。总共回顾性纳入了7131例患者，其中582例（8.2%）初次就诊时诊断为NSTEMI，940例（13.2%）发生了180天主要不良心血管事件（MACE）。对于HEAR评分低风险（0至2分）且0小时hs-cTnT低（<14 ng/L）的患者，HEAR路径建议早期出院，无需进一步检测。在应用HEAR路径排除NSTEMI后，初次就诊时NSTEMI的阴性预测值为100.0%（95%CI，99.8%至100.0%），180天MACE的假阴性率为0.40%（95%CI，0.18%至0.87%）。与0小时hs-cTnT<检测下限（LoD）策略（<5 ng/L）相比，HEAR路径可将1298例无MACE的患者正确重新分类为低风险，并使二次肌钙蛋白检测需求降低18.2%（95%CI，17.4 - 19.1%）。HEAR路径可能会大幅且安全地减少对急诊科疑似NSTEMI患者重复进行肌钙蛋白检测的情况。
