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.

References 16

1	van Nieuwkerk JL, van der Linden MC, Verheul RJ, Gaalen MVL, Janmaat M, van der Linden N. The impact of prehospital blood sampling on the emergency department process of patients with chest pain: a pragmatic non-randomized controlled trial. World J Emerg Med. 2023; 14(4):257-64. doi: 10.5847/wjem.j.1920-8642.2023.054 pmid: 37425086
2	McKenna P, Heslin SM, Viccellio P, Mallon WK, Hernandez C, Morley EJ. Emergency department and hospital crowding: causes, consequences, and cures. Clin Exp Emerg Med. 2019; 6(3):189-95. doi: 10.15441/ceem.18.022 pmid: 31295991
3	Redberg RF. Coronary CT angiography for acute chest pain. N Engl J Med. 2012; 367(4):375-6.
4	Than M, Flaws D, Sanders S, Doust J, Glasziou P, Kline J, et al. Development and validation of the Emergency Department Assessment of Chest pain Score and 2 h accelerated diagnostic protocol. Emerg Med Australas. 2014; 26(1):34-44. doi: 10.1111/1742-6723.12164 pmid: 24428678
5	Reichlin T, Hochholzer W, Bassetti S, Steuer S, Stelzig C, Hartwiger S, et al. Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. N Engl J Med. 2009; 361(9):858-67.
6	Kim MJ, Ha SO, Park YS, Yi JH, Yang WS, Kim JH. Validation and modification of HEART score components for patients with chest pain in the emergency department. Clin Exp Emerg Med. 2021; 8(4):279-88. doi: 10.15441/ceem.20.106 pmid: 35000355
7	Flaws D, Than M, Scheuermeyer FX, Christenson J, Boychuk B, Greenslade JH, et al. External validation of the Emergency Department Assessment of Chest Score accelerated diagnostic protocol (EDACS-ADP). Emerg Med J. 2016; 33(9):618-25.
8	Nilsson T, Johannesson E, Lundager Forberg J, Mokhtari A, Ekelund U. Diagnostic accuracy of the HEART pathway and EDACS-ADP when combined with a 0-hour/1-hour hs-cTnT protocol for assessment of acute chest pain patients. Emerg Med J. 2021; 38(11):808-13. doi: 10.1136/emermed-2020-210833 pmid: 33837120
9	Kip KE, Hollabaugh K, Marroquin OC, Williams DO. The problem with composite end points in cardiovascular studies: the story of major adverse cardiac events and percutaneous coronary intervention. J Am Coll Cardiol. 2008; 51(7):701-7. doi: 10.1016/j.jacc.2007.10.034 pmid: 18279733
10	Kim RB, Li A, Park KS, Kang YS, Kim JR, Navarese EP, et al. Low-dose aspirin for primary prevention of cardiovascular events comparing East Asians with Westerners: a meta-analysis. JACC Asia. 2023; 3(6):846-62.
11	Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA, et al. Fourth universal definition of myocardial infarction (2018). Circulation. 2018; 138(20):e618-e51.
12	Collet JP, Thiele H, Barbato E, Barthelemy O, Bauersachs J, Bhatt DL, et al. 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021; 42(14):1289-367.
13	Than M, Herbert M, Flaws D, Cullen L, Hess E, Hollander JE, et al. What is an acceptable risk of major adverse cardiac event in chest pain patients soon after discharge from the emergency department?: a clinical survey. Int J Cardiol. 2013; 166(3):752-4. doi: 10.1016/j.ijcard.2012.09.171 pmid: 23084108
14	Brenner H, Gefeller O. Variation of sensitivity, specificity, likelihood ratios and predictive values with disease prevalence. Stat Med. 1997; 16(9):981-91. doi: 10.1002/(sici)1097-0258(19970515)16:9<981::aid-sim510>3.0.co;2-n pmid: 9160493
15	Braunwald E, Morrow DA. Unstable angina: is it time for a requiem? Circulation. 2013; 127(24):2452-7. doi: 10.1161/CIRCULATIONAHA.113.001258 pmid: 23775194
16	Cullen L, Mueller C, Parsonage WA, Wildi K, Greenslade JH, Twerenbold R, et al. Validation of high-sensitivity troponin I in a 2-hour diagnostic strategy to assess 30-day outcomes in emergency department patients with possible acute coronary syndrome. J Am Coll Cardiol. 2013; 62(14):1242-9. doi: S0735-1097(13)01410-1 pmid: 23583250

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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