Use of the HEART Pathway with high sensitivity cardiac troponins: A secondary analysis

• Published in: Clinical biochemistry Vol. 50; no. 7-8; pp. 401 - 407
• Main Authors: Mahler, Simon A., Stopyra, Jason P., Apple, Fred S., Riley, Robert F., Russell, Gregory B., Hiestand, Brian C., Hoekstra, James W., Lefebvre, Cedric W., Nicks, Bret A., Cline, David M., Askew, Kim L., Herrington, David M., Burke, Gregory L., Miller, Chadwick D.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-05-2017
• Subjects: Acute coronary syndrome; Adult; Aged; Chest pain; Female; HEART Pathway; Humans; Male; Middle Aged; Myocardial Infarction - blood; Predictive Value of Tests; Troponin; Troponin C - blood; RCT; NRI; CI; Chest pain; HEART Pathway; EMR; ADP; URL; ACS; Troponin; MACE; NPV; hs-cTn; cTn; MI; Acute coronary syndrome; ED
• ISSN: 0009-9120; 1873-2933
• DOI: 10.1016/j.clinbiochem.2017.01.003

The HEART Pathway combines a decision aid and serial contemporary cardiac troponin I (cTnI) measures to achieve >99% sensitivity for major adverse cardiac events (MACE) at 30days and early discharge rates >20%. However, the impact of integrating high-sensitivity troponin (hs-cTn) measures into the HEART Pathway has yet to be determined. In this analysis we compare test characteristics of the HEART Pathway using hs-cTnI, hs-cTnT, or cTnI.
A secondary analysis of participants enrolled in the HEART Pathway RCT was conducted. Each patient was risk stratified by the cTn-HEART Pathway (Siemens TnI-Ultra at 0- and 3-h) and a hs-cTn-HEART Pathway using hs-cTnI (Abbott) or hs-cTnT (Roche) at 3-h. The early discharge rate, sensitivity, specificity, and negative predictive value (NPV) for MACE (death, myocardial infarction, or coronary revascularization) at 30days were calculated.
hs-cTnI measures were available on 133 patients. MACE occurred in 11/133 (8%) of these patients. Test characteristics for the HEART Pathway using serial cTnI vs 3hour hs-cTnI were the same: sensitivity (100%, 95%CI: 72–100%), specificity (49%, 95%CI: 40–58%), NPV (100%, 95%CI: 94–100%), and early discharge rate (45%, 95%CI: 37–54%). The HEART Pathway using hs-cTnT missed one MACE event (myocardial infarction): sensitivity (91%, 95%CI: 59–100%), specificity (48%, 95%CI: 39–57%), NPV (98%, 95%CI: 91–100%), and early discharge rate (45%, 95%CI: 37–54%).
There was no difference in the test characteristics of the HEART Pathway whether using cTnI or hs-cTnI, with both achieving 100% sensitivity and NPV. Use of hs-cTnT with the HEART Pathway was associated with one missed MACE.
•The HEART Pathway using cTnI or hs-cTnI achieved 100% sensitivity and NPV for MACE.•HEART Pathway test characteristics using hs-cTnT were similar to cTnI and hs-cTnI.•Use of the HEART Pathway with hs-cTnT did result in one missed MACE.•Without the HEART Pathway, hs-cTn measures were insufficiently sensitive.