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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
  1. Tsvetelina Nilsson1,
  2. Erik Johannesson2,
  3. Jakob Lundager Forberg3,
  4. Arash Mokhtari4,
  5. Ulf Ekelund1
  1. 1Department of Emergency Medicine, Skåne University Hospital Lund, Lund University, Lund, Sweden
  2. 2Department of Emergency Medicine, Lund University, Lund, Sweden
  3. 3Department of Emergency Medicine and Prehospital Care, Helsingborgs lasarett, Helsingborg, Sweden
  4. 4Department of Cardiology, Skåne University Hospital Lund, Lund, Sweden
  1. Correspondence to Dr Tsvetelina Nilsson, Department of Emergency Medicine, Skåne University Hospital Lund, Lund, Skåne, Sweden; drcmarkova{at}


Background/aim In ED chest pain patients, a 0-hour/1-hour protocol based on high sensitivity cardiac troponin T (hs-cTnT) tests combined with clinical risk stratification in diagnosing acute coronary syndrome is recommended. Two of the most promising risk stratification tools are the History, ECG, Age, Risk Factors and Troponin (HEART) and Emergency Department Assessment of Chest Pain (EDAC) scores. Few studies have assessed the diagnostic accuracy of the 0-hour/1-hour hs-cTnT protocol when combined with HEART score, and none with EDACS. In ED chest pain patients, we aimed to evaluate the diagnostic accuracy of a 0-hour/1-hour hs-cTnT protocol combined the HEART Pathway, or the EDACS accelerated diagnostic pathway (EDACS-ADP).

Methods This was a secondary analysis of data from a prospective observational study enrolling 1167 ED chest pain patients who visited the ED at Skåne University Hospital in Lund, Sweden in the period between February 2013 and April 2014. HEART and EDAC scores were assessed together with hs-cTnT at 0 and 1 hour and compared with HEART score alone. Sensitivity, specificity, negative predictive value (NPV) and likelihood ratios were evaluated. The primary outcome was major adverse cardiac events (MACE) including unstable angina within 30 days. The secondary outcome was index visit acute myocardial infarction (AMI).

Results A total of 939 patients were included in the final analysis. When combined with 0-hour/1-hour hs-cTnT testing, the HEART Pathway and EDACS-ADP identified 49.8% and 49.6% of the patients for rule-out, with NPVs for 30-day MACE of 99.8% and 99.1%, compared with the HEART score alone that identified 53.4% of the patients for rule-out with NPV of 99.2%. The NPV for index visit AMI were 100%, 99.8% and 99.2%, respectively.

Conclusion The combination of the HEART Pathway or the EDACS-ADP with a 0-hour/1-hour hs-cTnT protocol allows safe and early rule-out in a large proportion of ED chest pain patients.

  • cardiac care
  • acute myocardal infarct
  • acute coronary syndrome
  • diagnosis

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Handling editor Edward Carlton

  • AM and UE contributed equally.

  • Contributors All authors have read and approved the final manuscript and meet the criteria for authorship as established by the ICMJE.

  • Funding The study was supported by an ALF research grant (grant no. 2018-Projekt0152) at Skåne University Hospital and by a grant from Region Skåne (grant no. REGSKANE-814271). These are grants from the Swedish government and the regional council. There was no industry involvement. This study was part of the AIR Lund (Artificially Intelligent use of Registers at Lund University) research environment, and received funding from the Swedish Research Council (VR; grant no. 2019-00198). Further funding was provided by a grant from the Heart-Lung fund (Hjärt-Lungfonden, grant no. 20180173). Funding organisations had no role in the planning, design, or conduct of the study, collection, analysis or interpretation of data, or preparation, review or approval of the manuscript.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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