title: Use of the HEART Pathway with high sensitivity cardiac troponins: A secondary analysis.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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%).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA. Electronic address: smahler@wakehealth.edu.
authors.forename: Simon A
authors.initials: SA
authors.lastname: Mahler
authors.affiliation: Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.
authors.forename: Jason P
authors.initials: JP
authors.lastname: Stopyra
authors.affiliation: Department Laboratory Medicine and Pathology, Hennepin County Medical Center and University of Minnesota Medical School, Minneapolis, MN, USA.
authors.forename: Fred S
authors.initials: FS
authors.lastname: Apple
authors.affiliation: Division of Cardiology, University of Washington, Seattle, WA, USA.
authors.forename: Robert F
authors.initials: RF
authors.lastname: Riley
authors.affiliation: Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA.
authors.forename: Gregory B
authors.initials: GB
authors.lastname: Russell
authors.affiliation: Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.
authors.forename: Brian C
authors.initials: BC
authors.lastname: Hiestand
authors.affiliation: Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.
authors.forename: James W
authors.initials: JW
authors.lastname: Hoekstra
authors.affiliation: Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.
authors.forename: Cedric W
authors.initials: CW
authors.lastname: Lefebvre
authors.affiliation: Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.
authors.forename: Bret A
authors.initials: BA
authors.lastname: Nicks
authors.affiliation: Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.
authors.forename: David M
authors.initials: DM
authors.lastname: Cline
authors.affiliation: Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.
authors.forename: Kim L
authors.initials: KL
authors.lastname: Askew
authors.affiliation: Department of Internal Medicine, Division of Cardiology, Wake Forest School of Medicine, Winston-Salem, NC, USA.
authors.forename: David M
authors.initials: DM
authors.lastname: Herrington
authors.affiliation: Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA.
authors.forename: Gregory L
authors.initials: GL
authors.lastname: Burke
authors.affiliation: Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA.
authors.forename: Chadwick D
authors.initials: CD
authors.lastname: Miller
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000097:blood*; D011237:Predictive Value of Tests; D019209:Troponin C / Q000097:blood*
chemical_list: D019209:Troponin C
keywords: Acute coronary syndrome; Chest pain; HEART Pathway; Troponin