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Background The objective of this study was to quantify the sensitivity of very low concentrations of high‐sensitivity cardiac troponin T (hsTnT) at ED arrival for acute myocardial infarction (AMI) in a large cohort of chest pain patients evaluated in real‐world clinical practice. Methods This retrospective study included consecutive ED patients with suspected cardiac chest pain evaluated in four urban EDs, excluding those with ST‐elevation AMI, cardiac arrest or abnormal kidney function. The primary outcomes were AMI at 7, 30, and 90 days. Secondary outcomes included major adverse cardiac events (MACE; all‐cause mortality, AMI, and revascularization) and the individual MACE components. Test characteristics were calculated for hsTnT values from 3 to 200 ng/L . Results A total of 7,130 patients met inclusion criteria. AMI incidences at 7, 30, and 90 days were 5.8, 6.0, and 6.2%. When the hsTnT assay was performed at ED arrival, the limit of blank of the assay (3 ng/L) ruled out 7‐day AMI in 15.5% of patients with 100% sensitivity and negative predictive value (NPV). The limit of detection of the assay (5 ng/L) ruled out AMI in 33.6% of patients with 99.8% sensitivity and 99.95% NPV for 7‐day AMI. The limit of quantification (the Food and Drug Administration [FDA]‐approved cutoff for lower the reportable limit) of 6 ng/L ruled out AMI in 42.2% of patients with 99.8% sensitivity and 99.95% NPV. The sensitivities of the cutoffs of

Objective The objective was to determine the impact of the HEART Pathway on health care utilization and safety outcomes at 1 year in patients with acute chest pain. Methods Adult emergency department (ED) patients with chest pain (N = 282) were randomized to the HEART Pathway or usual care. In the HEART Pathway arm, ED providers used the HEART score and troponin measures (0 and 3 hours) to risk stratify patients. Usual care was based on American College of Cardiology/American Heart Association guidelines. Major adverse cardiac events (MACE-cardiac death, myocardial infarction [MI], or coronary revascularization), objective testing (stress testing or coronary angiography), and cardiac hospitalizations and ED visits were assessed at 1 year. Randomization arm outcomes were compared using Fisher's exact tests. Results A total of 282 patients were enrolled, with 141 randomized to each arm. MACE at 1 year occurred in 10.6% (30/282): 9.9% in the HEART Pathway arm (14/141; 10 MIs, four revascularizations without MI) versus 11.3% in usual care (16/141; one cardiac death, 13 MIs, two revascularizations without MI; p = 0.85). Among low-risk HEART Pathway patients, 0% (0/66) had MACE, with a negative predictive value (NPV) of 100% (95% confidence interval = 93%-100%). Objective testing through 1 year occurred in 63.1% (89/141) of HEART Pathway patients compared to 71.6% (101/141) in usual care (p = 0.16). Nonindex cardiac-related hospitalizations and ED visits occurred in 14.9% (21/141) and 21.3% (30/141) of patients in the HEART Pathway versus 10.6% (15/141) and 16.3% (23/141) in usual care (p = 0.37, p = 0.36). Conclusions The HEART Pathway had a 100% NPV for 1-year safety outcomes (MACE) without increasing downstream hospitalizations or ED visits. Reduction in 1-year objective testing was not significant.

Approximately 8 to 10 million patients complaining of chest pain present to emergency departments (EDs) annually in the United States.1 In an attempt to avoid missing the diagnosis of acute coronary syndrome (ACS), emergency physicians use liberal testing strategies in patients with acute chest pain. This results in more than 50% of ED patients with acute chest pain receiving comprehensive cardiac evaluations (serial cardiac biomarkers and stress testing or angiography) at an estimated cost of $10 to $13 billion annually,2–6 yet fewer than 10% of these patients are ultimately diagnosed with ACS.6–10 Current care patterns for patients with acute chest pain fail to focus health system resources on patients likely to benefit. Among low-risk patients who have ACS rates as low as 2%, stress testing and cardiac imaging is associated with a substantial number of false-positive and nondiagnostic tests, which leads to additional unnecessary and often invasive procedures.11 Consensus among health system leaders, clinicians, and educators is building regarding the need to more efficiently evaluate patients with acute chest pain.12 The 2-hour accelerated diagnostic protocol (ADAPT),13,14 which combines 0- and 2-hour cardiac troponin (cTn) tests, electrocardiograms (ECGs), and an adapted Thombolysis in Myocardial Infarction (TIMI) score, is a recently developed decision rule designed to identify ED patients safe for early discharge. Previous studies in the Asia-Pacific region have demonstrated that ADAPT can classify 20% of patients with acute chest pain for early discharge while simultaneously achieving high sensitivity (97.9% to 99.7%) for major adverse cardiac events (MACE) at 30 days.13,15 Based on these studies, many believe that ADAPT has the potential to more efficiently focus inpatient resources and objective cardiac testing (stress testing or angiography) on patients likely to benefit. However, the performance of ADAPT within a cohort of US ED patients has yet to be examined. We designed a secondary data analysis of the American College of Radiology Imaging Network (ACRIN) PA 4005 cohort to determine the validity of ADAPT in a group of U.S. ED patients with suspected ACS. Specifically we sought to determine if ADAPT can classify 20% or more patients with acute chest pain as safe for early discharge while maintaining high sensitivity and negative predictive value (NPV) for MACE. While the precise value of an acceptable sensitivity and NPV for MACE is a matter of considerable debate, many believe that a successful chest pain risk stratification strategy must achieve >99% NPV (corresponding with a < 1% missed MACE rate among patients with a low-risk assessment) and approach a 99% sensitivity.16