PT  - JOURNAL ARTICLE
AU  - Lane M. Smith
AU  - Nicklaus P. Ashburn
AU  - Anna C. Snavely
AU  - Jason P. Stopyra
AU  - Kristin M. Lenoir
AU  - Brian J. Wells
AU  - Brian C. Hiestand
AU  - David M. Herrington
AU  - Chadwick D. Miller
AU  - Simon A. Mahler
TI  - Identification of very low-risk acute chest pain patients without troponin testing
AID  - 10.1136/emermed-2020-209698
DP  - 2020 Nov 01
TA  - Emergency Medicine Journal
PG  - 690--695
VI  - 37
IP  - 11
4099  - http://emj.bmj.com/content/37/11/690.short
4100  - http://emj.bmj.com/content/37/11/690.full
SO  - Emerg Med J2020 Nov 01; 37
AB  - Background The HEART Pathway combines a History ECG Age Risk factor (HEAR) score and serial troponins to risk stratify patients with acute chest pain. However, it is unclear whether patients with HEAR scores of <1 require troponin testing. The objective of this study is to measure the major adverse cardiac event (MACE) rate among patients with <1 HEAR scores and determine whether serial troponin testing is needed to achieve a miss rate <1%.Methods A secondary analysis of the HEART Pathway Implementation Study was conducted. HEART Pathway risk assessments (HEAR scores and serial troponin testing at 0 and 3 hours) were completed by the providers on adult patients with chest pain from three US sites between November 2014 and January 2016. MACE (composite of death, myocardial infarction (MI) and coronary revascularisation) at 30 days was determined. The proportion of patients with HEAR scores of <1 diagnosed with MACE within 30 days was calculated. The impact of troponin testing on patients with HEAR scores of <1 was determined using Net Reclassification Improvement Index (NRI).Results Providers completed HEAR assessments on 4979 patients and HEAR scores<1 occurred in 9.0% (447/4979) of patients. Among these patients, MACE at 30 days occurred in 0.9% (4/447; 95% CI 0.2% to 2.3%) with two deaths, two MIs and 0 revascularisations. The sensitivity and negative predictive value for MACE in the HEAR <1 was 97.8% (95%CI 94.5% to 99.4%) and 99.1% (95% CI 97.7% to 99.8%), respectively, and were not improved by troponin testing. Troponin testing in patients with HEAR <1 correctly reclassified two patients diagnosed with MACE, and was elevated among seven patients without MACE yielding an NRI of 0.9% (95%CI −0.7 to 2.4%).Conclusion These data suggest that patients with HEAR scores of 0 and 1 represent a very low-risk group that may not require troponin testing to achieve a missed MACE rate <1%. Trial registration number NCT02056964