Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non–ST-Elevation Acute Coronary Syndromes

Nestler, David M.; Sudhir, Amita; Brown, Michael D.; Wolf, Stephen J.; Byyny, Richard L.; Diercks, Deborah B.; Gemme, Seth R.; Gerardo, Charles J.; Godwin, Steven A.; Hahn, Sigrid A.; Harrison, Nick; Hatten, Benjamin W.; Haukoos, Jason S.; Kaji, Amy H.; Kwok, Heemun; Lo, Bruce M.; Mace, Sharon E.; Nazarian, Devorah J.; Proehl, Jean A.; Promes, Susan B.; Shah, Kaushal; Shih, Richard D.; Silvers, Scott M.; Smith, Michael D.; Thiessen, Molly E.W.; Tomaszewski, Christian; Valente, Jonathan H.; Wall, Stephen P.; Cantrill, Stephen V.; Hirshon, Jon Mark; Schulz, Travis; Whitson, Rhonda R.

doi:10.1016/j.annemergmed.2018.07.045

Cited by 71 publications

(57 citation statements)

References 105 publications

(196 reference statements)

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“…Patients diagnosed with chest pain and discharged home from the ED in the province of Ontario, Canada have a 1% composite outcome (all-cause death, MI, UA hospital admission) at one month. This is in agreement with acceptable recommendations from emergency physician groups on miss rates in ED patients with possible ACS symptoms [ 23 , 24 ]. However, within this group of patients, the CCS can further aid in risk stratification.…”

Section: Discussionsupporting

confidence: 88%

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Risk Stratification for Patients with Chest Pain Discharged Home from the Emergency Department

Kavsak

Cerasuolo

Mondoux

et al. 2020

JCM

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For patients with chest pain who are deemed clinically to be low risk and discharged home from the emergency department (ED), it is unclear whether further laboratory tests can improve risk stratification. Here, we investigated the utility of a clinical chemistry score (CCS), which comprises plasma glucose, the estimated glomerular filtration rate, and high-sensitivity cardiac troponin (I or T) to generate a common score for risk stratification. In a cohort of 14,676 chest pain patients in the province of Ontario, Canada and who were discharged home from the ED (November 2012–February 2013 and April 2013–September 2015) we evaluated the CCS as a risk stratification tool for all-cause mortality, plus hospitalization for myocardial infarction or unstable angina (primary outcome) at 30, 90, and 365 days post-discharge using Cox proportional hazard models. At 30 days the primary outcome occurred in 0.3% of patients with a CCS < 2 (n = 6404), 0.9% of patients with a CCS = 2 (n = 4336), and 2.3% of patients with a CCS > 2 (n = 3936) (p < 0.001). At 90 days, patients with CCS < 2 (median age = 52y (IQR = 46–60), 59.4% female) had an adjusted HR = 0.51 (95% confidence interval (CI) = 0.32–0.82) for the composite outcome and patients with a CCS > 2 (median age = 74y (IQR = 64–82), 48.0% female) had an adjusted HR = 2.80 (95%CI = 1.98–3.97). At 365 days, 1.3%, 3.4%, and 11.1% of patients with a CCS < 2, 2, or >2 respectively, had the composite outcome (p < 0.001). In conclusion, the CCS can risk stratify chest pain patients discharged home from the ED and identifies both low- and high-risk patients who may warrant different medical care.

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Section: Discussionsupporting

confidence: 88%

“…A miss event rate of 1% for an acute ischemic event/death for discharged ED patients at 30 days is considered by several emergency medicine groups to be acceptable [ 23 , 24 ]. Accordingly, we set the score from the CCS that achieved close to 1% event rate at 30 days as the referent group.…”

Section: Methodsmentioning

confidence: 99%

Risk Stratification for Patients with Chest Pain Discharged Home from the Emergency Department

Kavsak

Cerasuolo

Mondoux

et al. 2020

JCM

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“…The recent American College of Emergency Physicians' clinical policy on management of ED patients with non-STelevation ACS discourages the routine use of further diagnostic testing such as stress test or computed tomography angiography prior to discharge in low-risk patients. [2] Our study does have some limitations, 13.7% of patients had TnI measurements before the 3-hour mark. However, these patients did not suffer from MACE misdiagnosis.…”

Section: Discussionmentioning

confidence: 88%

“…[1] Chest pain constitutes approximately 5% of all ED visits translating to approximately 10 million ED visits in the US annually, and acute myocardial infarction (AMI) hospitalization is costly. [2,3] One of the main objectives of ED evaluation of patients with chest pain or other anginal equivalent symptoms (e.g. shortness of breath, chest discomfort, indigestion) is to the rule-out acute coronary syndrome (ACS).…”

Section: Introductionmentioning

confidence: 99%

Use of conventional cardiac troponin assay for diagnosis of non-ST-elevation myocardial infarction: ‘The Ottawa Troponin Pathway’

Thiruganasambandamoorthy

Stiell

Chaudry

et al. 2020

PLoS ONE

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Background Serial conventional cardiac troponin (cTn) measurements 6-9 hours apart are recommended for non-ST-elevation MI (NSTEMI) diagnosis. We sought to develop a pathway with 3-hour changes for major adverse cardiac event (MACE) identification and assess the added value of the HEART [History, Electrocardiogram (ECG), Age, Risk factors, Troponin] score to the pathway. Methods We prospectively enrolled adults with NSTEMI symptoms at two-large emergency departments (EDs) over 32-months. Patients with STEMI, unstable angina and one cTn were excluded. We collected baseline characteristics, Siemens Vista conventional cTnI at 0, 3 or 6-hours after ED presentation; HEART score predictors; disposition and ED length of stay (LOS). Adjudicated primary outcome was 15-day MACE (acute MI, revascularization, or death due to cardiac ischemia/unknown cause). We analyzed multiples of 99th percentile cutoff cTnI values (45, 100 and 250ng/L). Results 1,683 patients (mean age 64.7 years; 55.3% female; median LOS 7-hours; 88 patients with 15-day MACE) were included. 1,346 (80.0%) patients with both cTnI�45 ng/L; and 155 (9.2%) of the 213 patients with one value�100ng/L but both<250ng/L or �20% change did not suffer MACE. Among 124 patients (7.4%) with one of the two values>45ng/L but<100ng/L based on 3 or 6-hour cTnI, one patient with absolute change<10ng/L and 6 of the 19 patients with�20ng/L were diagnosed with NSTEMI (patients with Δ10-19ng/L between first and second cTnI had third one at 6-hours). Based on the results, we developed the Ottawa Troponin Pathway (OTP) with a 98.9% sensitivity (95% CI 93.8-100%) and 94.6%

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“…Each year, approximately 10 million people in the US present to the ED with signs and symptoms suggestive of AMI; of these, 625,000 patients (∼6.25%) are diagnosed with ACS. Of the 625,000 ACS patients, 70% (437,500) are ultimately diagnosed with non–ST-elevation (NSTE)-ACS (NSTEMI plus unstable angina) that are often not identified by the ECG [ 27 , 28 ]. Accurate and rapid identification of AMI patients is critical to saving lives, and avoiding unnecessary procedures, lengthy stays and overcrowding in EDs, patient anxiety, and associated healthcare costs [ 2 , 10 , [29] , [30] , [31] ].…”

Section: Discussionmentioning

confidence: 99%

Trial design for assessing analytical and clinical performance of high-sensitivity cardiac troponin I assays in the United States: The HIGH-US study

Christenson

Peacock

Apple

et al. 2019

Contemporary Clinical Trials Communications

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Background High-sensitivity cardiac troponin I (hs-cTnI) assays have been developed that quantify lower cTnI concentrations with better precision versus earlier generation assays. hs-cTnI assays allow improved clinical utility for diagnosis and risk stratification in patients presenting to the emergency department with suspected acute myocardial infarction. We describe the High-Sensitivity Cardiac Troponin I Assays in the United States (HIGH-US) study design used to conduct studies for characterizing the analytical and clinical performance of hs-cTnI assays, as required by the US Food and Drug Administration for a 510(k) clearance application. This study was non-interventional and therefore it was not registered at clinicaltrials.gov. Methods We conducted analytic studies utilizing Clinical and Laboratory Standards Institute guidance that included limit of blank, limit of detection, limit of quantitation, linearity, within-run and between run imprecision and reproducibility as well as potential interferences and high dose hook effect. A sample set collected from healthy females and males was used to determine the overall and sex-specific cTnI 99th percentile upper reference limits (URL). The total coefficient of variation at the female 99th percentile URL and a universally available American Association for Clinical Chemistry sample set (AACC Universal Sample Bank) from healthy females and males was used to examine high-sensitivity (hs) performance of the cTnI assays. Clinical diagnosis of enrolled subjects was adjudicated by expert cardiologists and emergency medicine physicians. Assessment of temporal diagnostic accuracy including sensitivity, specificity, positive predictive value, and negative predictive value were determined at presentation and collection times thereafter. The prognostic performance at one-year after presentation to the emergency department was also performed. This design is appropriate to describe analytical characterization and clinical performance, and allows for acute myocardial infarction diagnosis and risk assessment.

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Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non–ST-Elevation Acute Coronary Syndromes

Cited by 71 publications

References 105 publications

Risk Stratification for Patients with Chest Pain Discharged Home from the Emergency Department

Risk Stratification for Patients with Chest Pain Discharged Home from the Emergency Department

Use of conventional cardiac troponin assay for diagnosis of non-ST-elevation myocardial infarction: ‘The Ottawa Troponin Pathway’

Trial design for assessing analytical and clinical performance of high-sensitivity cardiac troponin I assays in the United States: The HIGH-US study

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