Major adverse cardiac event rates in moderate‐risk patients: Does prior coronary disease matter?

Abstract

Background: Despite negative troponins and nonischemic electrocardiograms (ECGs), patients at moderate risk for acute coronary syndrome (ACS) are frequently admitted.The objective of this study was to describe the major adverse cardiac event (MACE) rate in moderate-risk patients and how it differs based on history of coronary artery disease (CAD).Methods: A secondary analysis of the HEART Pathway implementation study was conducted. This prospective interrupted time-series study accrued adults with possible ACS from three sites (November 2013-January 2016). This analysis excluded low-risk patients determined by emergency providers' HEART Pathway assessments.Non-low-risk patients were further classified as high risk, based on elevated troponin measures or ischemic ECG findings or as moderate risk, based on HEAR score ≥ 4, negative troponin measures, and a nonischemic ECG. Moderate-risk patients were then stratified by the presence or absence of prior CAD (MI, revascularization, or ≥70% coronary stenosis). MACE (death, myocardial infarction, or revascularization) at 30 days was determined from health records, insurance claims, and death index data. MACE rates were compared among groups using a chi-square test and likelihood ratios (LRs) were calculated.Results: Among 4,550 patients with HEART Pathway assessments, 24.8%(1,130/4,550) were high risk and 37.7% (1715/4550) were moderate risk. MACE at 30 days occurred in 3.1% (53/1,715; 95% confidence interval [CI] = 2.3% to 4.0%) of moderate-risk patients. Among moderate-risk patients, MACE occurred in 7.1% (36/508, 95% CI = 5.1% to 9.8%) of patients with known CAD versus 1.4% (17/1,207, 95% CI = 0.9% to 2.3%) in patients without known prior CAD (p < 0.0001). The negative LR for 30-day MACE among moderate-risk patients without prior CAD was 0.08 (95% CI = 0.05 to 0.12).

A streamlined Emergency Department approach to moderate risk chest pain in patients with no pre‐existing coronary artery disease: A pilot study

“…Despite the moderate risk stratification there were no serious adverse events in our study, with only two patients undergoing angiography within 30 days, one of whom progressed to PCI; this was despite a follow‐up time to initial cardiac investigation being on average 31 days post ED discharge. Consistent with recent data suggesting a MACE of 1.7% in moderate risk patients with no pre‐existing CAD, 10 this lack of MACE despite a prolonged time to testing suggests that the pathway is relatively safe, although a study of this size was not powered to detect a statistical difference in MACE between the cohorts and this needs confirmation by a larger study.…”

“…NHFA/CSANZ guidelines recommend that further diagnostic imaging be performed on moderate risk patients to provide prognostic information, and that this testing be done during or shortly after discharge from ED 6 with no specific timing suggested. This moderate risk group is, however, a heterogenous group of patients with a risk of MACE somewhere between 2% and 8%, 8–10 10%–20% of whom will already have had previous cardiac imaging, 9 and trying to further delineate risk among the subgroups within this cohort is complex. As such, various management strategies are employed in this group and many of these patients are admitted from the ED for short stay inpatient management, including changes in medical therapy or functional testing.…”

The HEART Pathway: Just a HEART score permutation or the future of clinical decision rules?

“…In this issue of Academic Emergency Medicine , McGinnis et al 12 provide a novel analysis assessing the impact of a history of coronary artery disease (CAD) on the rate of MACE among patients classified as moderate risk by the HEART Pathway. They found that a reported history of CAD in patients classified as moderate risk conferred an increased risk of MACE compared to those without reported CAD.…”

“…Recently, with the development of the Heart Pathway's mobile-based application as well as an integrated electronic health record (EHR) clinical decision support (CDS) tool, 10 it has begun to find broader adoption outside its derivation environment. 11 In this issue of Academic Emergency Medicine, McGinnis et al 12 provide a novel analysis assessing the impact of a history of coronary artery disease (CAD) on the rate of MACE among patients classified as moderate risk by the HEART Pathway. They found that a reported history of CAD in patients classified as moderate risk conferred an increased risk of MACE compared to those without reported CAD.…”