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ACC Chest Pain Pathway Validation
Quick Takes
- The ACC Pathway, using a 0- and 2-hour hs-cTnI approach, was safe and efficacious within a multisite US emergency department cohort of patients with possible ACS.
- However, the performance of the ACC Pathway was somewhat suboptimal in patients with known CAD.
- This suggests the need for additional research to develop optimal strategies for evaluation, risk stratification, and management of patients with established CAD presenting with chest pain.
Study Questions:
What is the validity of the American College of Cardiology Expert Consensus Decision Pathway (ACC Pathway) for chest pain in a multisite US cohort?
Methods:
The investigators conducted an observational cohort study of adults with possible acute coronary syndrome (ACS). Patients were accrued from five US emergency departments (EDs) from November 1, 2020–July 31, 2022. Electrocardiograms and 0- and 2-hour high-sensitivity troponin (Beckman Coulter) measures were used to stratify patients according to the ACC Pathway. The primary safety outcome was 30-day all-cause death or myocardial infarction (MI). Efficacy was defined as the proportion stratified to the rule-out zone. Negative predictive value for 30-day death or MI was assessed among the whole cohort and in a subgroup of patients with coronary artery disease (CAD) (prior MI, revascularization, or ≥70% coronary stenosis).
Results:
ACC Pathway assessments were complete in 14,395 patients, of whom 51.7% (7,437/14,395) were female with a median age of 56 (interquartile range, 44-68) years. Known CAD was present in 23.5% (3,386/14,395) and 30-day death or MI occurred in 8.1% (1,168/14,395). The ACC Pathway had an efficacy of 48.1% (95% confidence interval [CI], 47.3-49.0). Among patients in the rule-out zone, 0.3% (22/6,930) had death or MI at 30 days, yielding a negative predictive value of 99.7% (95% CI, 99.5-99.8%). In patients with known CAD, 20.0% (676/3,386) were classified to the rule-out zone, of which 1.5% (10/676) had death or MI.
Conclusions:
The authors report that the ACC Expert Consensus Decision Pathway was safe and efficacious.
Perspective:
This multisite US ED cohort study reports that the ACC Pathway, using a 0- and 2-hour high-sensitivity cardiac troponin I (hs-cTnI) approach, was safe and efficacious within a multisite US ED cohort of patients with possible ACS. These data would favor widespread adoption of the ACC Pathway within US EDs. However, the performance of the ACC Pathway was somewhat suboptimal in patients with known CAD with net predictive values of 98.5% for 30-day death or MI and 96.0% for 30-day major adverse cardiovascular events. This suggests the need for additional research to develop optimal strategies for evaluation, risk stratification, and management of patients with established CAD presenting with chest pain.
Clinical Topics: Acute Coronary Syndromes, ACS and Cardiac Biomarkers
Keywords: Acute Coronary Syndrome, Chest Pain
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