Dataset Information

Feasibility and Impact of the Combined Application of Coronary CT Angiography With the HEART Pathway in Patients With Suspected Acute Coronary Syndrome.

ABSTRACT:

Background

This study examines the feasibility and utility of integrating coronary computed tomography angiography and the HEART Pathway into a novel accelerated diagnostic protocol-called HEART-CT-and assesses its impact as an optional interactive decision support tool (smart form) in the electronic health record.

Methods

This was a retrospective observational study performed in 2 adult emergency departments (ED) among patients evaluated for suspected acute coronary syndrome. Primary outcomes included the rate of discharge from the ED following HEART-CT Smart Form use, 30-day major adverse cardiac events (MACE), and ED length of stay (LOS). Hypothesis-generating outcomes included the rate of Smart Form use by ED providers and whether adhering to the HEART-CT recommendations was associated with improved outcomes.

Results

The study included 672 subjects, 78.1% of whom were discharged from the ED. HEART-CT identified 76.7% of patients with increased risk HEAR scores as safe for discharge. No patients identified as low risk by HEART-CT had MACE within 30 days. Total mean ED LOS was 4.6 hours. ED providers used the HEART-CT smart form in 19.7% of eligible patients. ED providers who followed the HEART-CT recommendations had 3.41 times higher odds of ED discharging patients with increased risk HEAR scores than nonadherent providers (95% CI, 2.20-5.27).

Conclusions

HEART-CT reclassified a large proportion of patients as safe for discharge, maintained a high sensitivity for detecting 30-day MACE, and had an acceptable ED LOS. Future studies should test the extent to which more automated clinical decision support improves provider adoption and clinical outcomes of HEART-CT.

SUBMITTER: Matuskowitz AJ

PROVIDER: S-EPMC8408286 | biostudies-literature | 2021 Dec

REPOSITORIES: biostudies-literature

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Publications

Feasibility and Impact of the Combined Application of Coronary CT Angiography With the HEART Pathway in Patients With Suspected Acute Coronary Syndrome.

Matuskowitz Andrew J AJ Obeid Jihad S JS Jennings Lindsey L Bayer Richard R RR Ramakrishnan Viswanathan V Schoepf U Joseph UJ Jauch Edward C EC

Critical pathways in cardiology 20211201 4

<h4>Background</h4>This study examines the feasibility and utility of integrating coronary computed tomography angiography and the HEART Pathway into a novel accelerated diagnostic protocol-called HEART-CT-and assesses its impact as an optional interactive decision support tool (smart form) in the electronic health record.<h4>Methods</h4>This was a retrospective observational study performed in 2 adult emergency departments (ED) among patients evaluated for suspected acute coronary syndrome. Pri ...[more]

PMID: 33660627

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Project description:AimsCoronary computed tomography angiography is increasingly employed in the emergency department for suspected acute coronary syndrome patients. The HEART score has been proposed for initial risk stratification in these patients. The aim of this study was to investigate the diagnostic value and efficiency of the HEART score before coronary computed tomography angiography.Methods and resultsWe included patients suspected of acute coronary syndrome who underwent coronary computed tomography angiography in the emergency department. Based on the HEART score, patients were stratified as low-risk (HEART≤3), intermediate-risk (HEART4-6) and high-risk (HEART≥7). We assessed coronary computed tomography angiography for the presence of significant coronary artery disease (>50% stenosis). The primary outcome, the level of major adverse cardiac events, was a composite endpoint of all-cause mortality, acute coronary syndrome or coronary revascularisation within 30 days. The study population consisted of 340 patients (mean age: 55.6±10.1 years, 44.7% women), major adverse cardiac events occurred in 45 (13.2%) patients. The incidence of major adverse cardiac events in patients stratified as low-risk (35.0%), intermediate-risk (56.8%) and high-risk (8.2%) was 3.4%, 12.4% and 60.7%, respectively. All four low-risk patients with major adverse cardiac events had a HEART score of three. An algorithm where coronary computed tomography angiography is reserved for patients with HEART 3-6 resulted in a sensitivity of 97.8%, specificity of 84.1%, negative predictive value of 99.6% and positive predictive value of 48.4%, while reducing the need for coronary computed tomography angiography by 22% (n=75).ConclusionThe predictive value of coronary computed tomography angiography for 30-day major adverse cardiac events in suspected acute coronary syndrome patients is good, and reserving coronary computed tomography angiography for HEART score 3-6 patients reduces the number of needed coronary computed tomography angiograms without affecting diagnostic accuracy.

Project description:ObjectivesTo establish if the use of early computed tomography (CT) coronary angiography improves one year clinical outcomes in patients presenting to the emergency department with acute chest pain and at intermediate risk of acute coronary syndrome and subsequent clinical events.DesignRandomised controlled trial.Setting37 hospitals in the UK.ParticipantsAdults with suspected or a provisional diagnosis of acute coronary syndrome and one or more of previous coronary heart disease, raised levels of cardiac troponin, or abnormal electrocardiogram.InterventionsEarly CT coronary angiography and standard of care compared with standard of care only.Main outcome measuresPrimary endpoint was all cause death or subsequent type 1 or 4b myocardial infarction at one year.ResultsBetween 23 March 2015 and 27 June 2019, 1748 participants (mean age 62 years (standard deviation 13), 64% men, mean global registry of acute coronary events (GRACE) score 115 (standard deviation 35)) were randomised to receive early CT coronary angiography (n=877) or standard of care only (n=871). Median time from randomisation to CT coronary angiography was 4.2 (interquartile range 1.6-21.6) hours. The primary endpoint occurred in 51 (5.8%) participants randomised to CT coronary angiography and 53 (6.1%) participants who received standard of care only (adjusted hazard ratio 0.91 (95% confidence interval 0.62 to 1.35), P=0.65). Invasive coronary angiography was performed in 474 (54.0%) participants randomised to CT coronary angiography and 530 (60.8%) participants who received standard of care only (adjusted hazard ratio 0.81 (0.72 to 0.92), P=0.001). There were no overall differences in coronary revascularisation, use of drug treatment for acute coronary syndrome, or subsequent preventive treatments between the two groups. Early CT coronary angiography was associated with a slightly longer time in hospital (median increase 0.21 (95% confidence interval 0.05 to 0.40) days from a median hospital stay of 2.0 to 2.2 days).ConclusionsIn intermediate risk patients with acute chest pain and suspected acute coronary syndrome, early CT coronary angiography did not alter overall coronary therapeutic interventions or one year clinical outcomes, but reduced rates of invasive angiography while modestly increasing length of hospital stay. These findings do not support the routine use of early CT coronary angiography in intermediate risk patients with acute chest pain and suspected acute coronary syndrome.Trial registrationISRCTN19102565, NCT02284191.

Dataset Information

Feasibility and Impact of the Combined Application of Coronary CT Angiography With the HEART Pathway in Patients With Suspected Acute Coronary Syndrome.

Background

Methods

Results

Conclusions

Publications

Feasibility and Impact of the Combined Application of Coronary CT Angiography With the HEART Pathway in Patients With Suspected Acute Coronary Syndrome.

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