Identification of very low-risk acute chest pain patients without troponin testing.
Identification of very low-risk acute chest pain patients without troponin testing.
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DOI：
10.1136/emermed-2020-209698
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发表时间：
2020-11
期刊：
影响因子：
--
通讯作者：
Mahler SA
中科院分区：
文献类型：
--
作者：
Smith LM;Ashburn NP;Snavely AC;Stopyra JP;Lenoir KM;Wells BJ;Hiestand BC;Herrington DM;Miller CD;Mahler SA
HEART Pathway结合病史ECG年龄风险因素（HEAR）评分和系列肌钙蛋白对急性胸痛患者进行风险分层。然而，尚不清楚HEAR评分≤1的患者是否需要肌钙蛋白检测。本研究的目的是测量HEAR评分≤1的患者的主要不良心脏事件（MACE）发生率，并确定是否需要进行连续肌钙蛋白检测以达到漏诊率<1%。对HEART路径实施研究进行了二次分析。2014年11月至2016年1月期间，由提供者对来自美国三个研究中心的胸痛成人患者完成了心脏通路风险评估（0和3小时的HEAR评分和连续肌钙蛋白检测）。确定30天时的MACE（死亡、心肌梗死（MI）和冠状动脉血运重建的复合终点）。计算HEAR评分≤1的患者在30天内诊断为MACE的比例。使用净重新分类改善指数（NRI）确定肌钙蛋白检测对HEAR评分≤1的患者的影响。提供者对4979例患者完成了HEAR评估，9.0%（447/4979）的患者HEAR评分<1。在这些患者中，30天时的MACE发生率为0. 9%（4/447; 95% CI 0. 2%-2. 3%），其中2例死亡、2例MI和0例血运重建。HEAR ≤1的MACE敏感性和阴性预测值分别为97.8%（95%CI 94.5%至99.4%）和99.1%（95%CI 97.7%至99.8%），肌钙蛋白检测未改善。在HEAR ≤1的患者中，肌钙蛋白检测正确地重新分类了2例诊断为MACE的患者，在7例无MACE的患者中肌钙蛋白检测升高，NRI为0.9%（95%CI-0.7 - 2.4%）。这些数据表明，HEAR评分为0和1的患者代表极低风险组，可能不需要肌钙蛋白检测来实现MACE漏诊率<1%。 NCT02056964
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%. 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). 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%). 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%. NCT02056964
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