Performance of the EDACS-ADP Incorporating Highsensitivity Troponin Assay: Do Components of Major Adverse Cardiac Events Matter?

Overview

Journal World J Emerg Med

Specialty Emergency Medicine

Date 2024 Jun 10

PMID 38855369

Authors

Yedalm Yoo

Shin Ahn

Bora Chae

Won Young Kim

Affiliations

Soon will be listed here.

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% ]: 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% : 97.2%-99.6%) and 98.7% (95% : 97.0%-99.5%) for MACE I and 98.7% (95% : 96.8%-99.7%) and 99.0% (95% : 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.

References

Kim M, Ha S, Park Y, Yi J, Yang W, Kim J . Validation and modification of HEART score components for patients with chest pain in the emergency department. Clin Exp Emerg Med. 2022; 8(4):279-288. PMC: 8743685. DOI: 10.15441/ceem.20.106. View

Flaws D, Than M, Scheuermeyer F, Christenson J, Boychuk B, Greenslade J . External validation of the emergency department assessment of chest pain score accelerated diagnostic pathway (EDACS-ADP). Emerg Med J. 2016; 33(9):618-25. DOI: 10.1136/emermed-2015-205028. View

Reichlin T, Hochholzer W, Bassetti S, Steuer S, Stelzig C, Hartwiger S . Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. N Engl J Med. 2009; 361(9):858-67. DOI: 10.1056/NEJMoa0900428. View

Redberg R . Coronary CT angiography for acute chest pain. N Engl J Med. 2012; 367(4):375-6. DOI: 10.1056/NEJMe1206040. View

Collet J, Thiele H, Barbato E, Barthelemy O, Bauersachs J, Bhatt D . 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2020; 42(14):1289-1367. DOI: 10.1093/eurheartj/ehaa575. View

Braunwald E, Morrow D . Unstable angina: is it time for a requiem?. Circulation. 2013; 127(24):2452-7. DOI: 10.1161/CIRCULATIONAHA.113.001258. View

Kip K, Hollabaugh K, Marroquin O, Williams D . 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. View

Than M, Flaws D, Sanders S, Doust J, Glasziou P, Kline J . 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. View

McKenna P, Heslin S, Viccellio P, Mallon W, Hernandez C, Morley E . Emergency department and hospital crowding: causes, consequences, and cures. Clin Exp Emerg Med. 2019; 6(3):189-195. PMC: 6774012. DOI: 10.15441/ceem.18.022. View

10.

Than M, Herbert M, Flaws D, Cullen L, Hess E, Hollander J . 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. 2012; 166(3):752-4. DOI: 10.1016/j.ijcard.2012.09.171. View

11.

Nilsson T, Johannesson E, 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):808-813. DOI: 10.1136/emermed-2020-210833. View

12.

Thygesen K, Alpert J, Jaffe A, Chaitman B, Bax J, Morrow D . Fourth Universal Definition of Myocardial Infarction (2018). Circulation. 2018; 138(20):e618-e651. DOI: 10.1161/CIR.0000000000000617. View

13.

Cullen L, Mueller C, Parsonage W, Wildi K, Greenslade J, Twerenbold R . 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):1242-1249. DOI: 10.1016/j.jacc.2013.02.078. View

14.

Kim R, Li A, Park K, Kang Y, Kim J, Navarese E . Low-Dose Aspirin for Primary Prevention of Cardiovascular Events Comparing East Asians With Westerners: A Meta-Analysis. JACC Asia. 2023; 3(6):846-862. PMC: 10751647. DOI: 10.1016/j.jacasi.2023.07.008. View

15.

van Nieuwkerk J, van der Linden M, Verheul R, van Loon-van Gaalen M, 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):257-264. PMC: 10323509. DOI: 10.5847/wjem.j.1920-8642.2023.054. View

16.

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. View