Performance of the EDACS-ADP incorporating high-sensitivity troponin assay: Do components of major adverse cardiac events matter?

doi:10.5847/wjem.j.1920-8642.2024.032

Abstract

Abstract:

BACKGROUND: The accelerated diagnostic protocol (ADP) using the Emergency Department Assessment of Chest pain Score (EDACS-ADP), a tool to identify patients at low risk of a major adverse cardiac event (MACE) among patients presenting with chest pain to the emergency department, was developed using a contemporary troponin assay. This study was performed to validate and compare the performance of the EDACS-ADP incorporating high-sensitivity cardiac troponin I between patients who had a 30-day MACE with and without unstable angina (MACE I and II, respectively).
METHODS: A single-center prospective observational study of adult patients presenting with chest pain suggestive of acute coronary syndrome was performed. The performance of EDACS-ADP in predicting MACE was assessed by calculating the sensitivity and negative predictive value.
RESULTS: Of the 1,304 patients prospectively enrolled, 399 (30.6%; 95% confidence interval [95% CI]: 27.7%-33.8%) were considered low-risk using the EDACS-ADP. Among them, the rates of MACE I and II were 1.3% (5/399) and 1.0% (4/399), respectively. The EDACS-ADP showed sensitivities and negative predictive values of 98.8% (95% CI: 97.2%-99.6%) and 98.7% (95% CI: 97.0%-99.5%) for MACE I and 98.7% (95% CI: 96.8%-99.7%) and 99.0% (95% CI: 97.4%-99.6%) for MACE II, respectively.
CONCLUSION: EDACS-ADP could help identify patients as safe for early discharge. However, when unstable angina was added to the outcome, the 30-day MACE rate among the designated low-risk patients remained above the level acceptable for early discharge without further evaluation.

Key words: Chest pain, Major adverse cardiac event, Acute coronary syndrome, Emergency department

Yedalm Yoo, Shin Ahn, Bora Chae, Won Young Kim. Performance of the EDACS-ADP incorporating high-sensitivity troponin assay: Do components of major adverse cardiac events matter?[J]. World Journal of Emergency Medicine, 2024, 15(3): 175-180.

Figures/Tables 4

Table 1.

Figure 1.

Figure 2.

Table 2.

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Parameters	All patients (n=1,304)	MACE I ^a(+) (n=410)	MACE I ^a(-) (n=894)	P-value
Age, years, mean±SD	62.7±15.2	68.8±11.7	59.9±15.8	<0.001
Sex: Male, n (%)	790 (60.6)	289 (70.5)	501 (56.0)	<0.001
Cardiovascular risk factors, n (%)
Hypertension	621 (47.6)	245 (59.8)	376 (42.1)	<0.001
Diabetes	294 (22.5)	144 (35.1)	150 (16.8)	<0.001
Dyslipidemia	323 (24.8)	113 (27.6)	210 (23.5)	0.128
Family history of CAD	130 (10.0)	45 (11.0)	85 (9.5)	0.426
Cerebrovascular disease	97 (7.4)	35 (8.5)	62 (6.9)	0.308
Smoking: current or cessation <3 months	146 (11.2)	70 (17.1)	76 (8.5)	<0.001
Obesity (BMI ≥30 kg/m²)	62 (4.8)	18 (4.4)	44 (4.9)	0.780
History of CAD, n (%)
Acute myocardial infarction	90 (6.9)	43 (10.5)	47 (5.3)	0.001
Percutaneous coronary intervention	322 (24.7)	162 (39.5)	160 (17.9)	<0.001
Coronary artery bypass graft	53 (4.1)	25 (6.1)	28 (3.1)	0.015
Symptoms and signs, n (%)
Diaphoresis	253 (19.4)	132 (32.2)	121 (13.5)	<0.001
Radiation to the arm or shoulder	310 (23.8)	140 (34.1)	170 (19.0)	<0.001
Pain occurred or worsened with inspiration	91 (7.0)	5 (1.2)	86 (9.6)	<0.001
Pain reproduced by palpation	22 (1.7)	0 (0.0)	22 (2.5)	<0.001
Troponin I, ng/mL, median (IQR)
Initial (0 h)	0.01 (0.01-0.05)	0.04 (0.01-0.31)	0.01 (0.01-0.02)	<0.001
Follow-up (2 h)	0.01 (0.01-0.09)	0.08 (0.01-1.26)	0.01 (0.00-0.02)	<0.001
New ischemia on ECG, n (%)	356 (27.3)	201 (49.0)	155 (17.3)	<0.001

Groups	EDACS	ECG with hs-TnI	EDACS-ADP
MACE I ^a (+) (n=410, 31.4%)
Not-low risk, n (%)	368 (44.4)	273 (59.5)	405 (44.8)
Low risk, n (%)	42 (8.8)	137 (16.2)	5 (1.3)
Sensitivity ^b	89.8 (86.4-92.5)	66.6 (61.8-71.1)	98.8 (97.2-99.6)
MACE I ^a (-) (n=894, 68.6%)
Not-low risk, n (%)	461 (55.6)	186 (40.5)	500 (55.2)
Low risk, n (%)	433 (91.2)	708 (83.8)	394 (98.7)
Specificity ^b	48.4 (45.1-51.8)	79.2 (76.4-81.8)	44.1 (40.8-47.4)
Positive predictive value ^b	44.4 (42.6-46.2)	59.5 (55.9-62.9)	44.8 (43.3-46.2)
Negative predictive value ^b	91.2 (88.5-93.3)	83.8 (81.8-85.6)	98.7 (97.0-99.5)
MACE II ^c (+) (n=318, 24.4%)
Not-low risk, n (%)	282 (34.0)	232 (50.5)	314 (34.7)
Low risk, n (%)	36 (7.6)	86 (10.2)	4 (1.0)
Sensitivity ^b	88.7 (84.7-91.9)	73.0 (67.7-77.8)	98.7 (96.8-99.7)
MACE II ^c (-) (n=986, 75.6%)
Not-low risk, n (%)	547 (66.0)	227 (49.5)	591 (65.3)
Low risk, n (%)	439 (92.4)	759 (89.8)	395 (99.0)
Specificity ^b	44.5(41.4-47.7)	77.0 (74.2-80.0)	40.0 (37.0-43.2)
Positive predictive value ^b	34.0 (32.5-35.6)	50.5 (47.2-53.8)	34.7 (33.5-35.9)
Negative predictive value ^b	92.4 (89.9-94.3)	89.8 (88.0-91.4)	99.0 (97.4-99.6)
Rate of low-risk assigned, n (%) ^b	475 (36.4, 33.2-39.9)	845 (64.8, 60.5-69.3)	399 (30.6, 27.7-33.8)

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