The following is a summary of “Performance analysis considering endpoints for three accelerated diagnostic protocols for chest pain,” published in the November 2022 issue of Emergency Medicine by Chae, et al.

The three most well-known ADPs for patients with chest pain are the modified accelerated diagnostic protocol (ADP) to assess patients with chest pain symptoms using troponin as the only biomarker (mADAPT), the History, ECG, Age, Risk factors, and Troponin (HEART) pathway, and the Emergency Department Assessment of Chest Pain Rule (EDACS)-ADP. These ADPs exclude unstable angina as an endpoint and define major adverse cardiac events (MACE) as the sum of acute myocardial infarction, revascularization, and death.

The effectiveness of these 3 ADPs for patients with 30-day MACE with and without unstable angina was compared in a single-center prospective observational trial that researchers conducted. For MACE without unstable angina, which was the criterion utilized in score derivation research, they predicted that the ADPs would have high sensitivities. They would perform less admirably than the required level of >99% sensitivity when unstable angina was included in the MACE.

The analysis covered a total of 1,214 patients. Sensitivities for MACE were 99.1% (95% CI: 96.7-99.9%), 99.5% (95% CI: 97.4-100%), and 100% (95% CI: 98.3-100%) for mADAPT, EDACS-ADP, and HEART route, respectively, when unstable angina was excluded from the outcome. The HEART route showed the largest percentage of patients categorized as low risk (39.2%, 95% CI: 35.8-42.9%), followed by EDACS-ADP (31.3%, 95% CI: 28.2–34.6%), mADAPT (29.3%, 95% CI: 26.4–32.5%), and other pathways. When unstable angina was included in the MACE, sensitivities for mADAPT were 96.6% (95% CI: 94.4-98.1%), EDACS-ADP was 97.3% (95% CI: 95.3-98.6%), and the HEART route was 97.3% (95% CI: 95.3-98.6%). There were 15 false-negative instances with mADAPT and 12 each with the EDACS-ADP and HEART pathways.

When unstable angina was not included in the outcome, all three ADPs—mADAPT, EDACS-ADP, and HEART pathway—were equally accurate in their discriminatory performance for the risk categorization of ED patients presenting with potential ACS. The HEART route demonstrated the greatest sensitivity and percentage of patients who may be categorized as safe for early release. All three ADPs, however, did not exhibit adequate safety levels and their performances fell below the tolerable risk of MACE when unstable angina was included as an outcome.