The following summary is of “Derivation and validation of a high sensitivity troponin-T HEART pathway” published in the February 2023 issue of Heart by Snavely, et al.
However, the HEART Pathway has not been refined for high-sensitivity troponin T (hs-cTnT) assays, despite its widespread usage for determining risk in cases of chest pain. Therefore, researchers performed a secondary analysis of STOP-CP, prospective cohort research that included adult patients at 8 sites in the United States(US) with symptoms suggestive of the acute coronary syndrome. Each patient had their hs-cTnT tested at 0 and 1 hour, and their HEART score was calculated. To create a hs-cTnT HEART Pathway with rule-out, observation, and rule-in groups for 30-day cardiac death or myocardial infarction (MI), 729 randomly selected people were employed as a derivation set.
Generalized cross-validation was used to determine the best baseline and 1-hour troponin cutoffs to obtain an NPV of more than 99% for rule out and a PPV of more than 60% or maximum Youden index for rule in. To maximize the negative predictive value (NPV) in the rule-out group and positive predictive value (PPV) in the rule-in group, optimal 0-1-hour delta values were calculated using generalized cross-validation. In the remaining group (n=723), the efficacy of the hs-cTnT HEART Pathway was confirmed. However, 12.7% (184/1452) of the patients died or had a heart attack within 30 days. The ideal hs-cTnT HEART Pathway within the derivation cohort categorized 36.5 % (266/729) into the rule-out group, with an NPV of 99.2 % (98.5 % confidence interval [CI]: 98.2 to 100) for 30-day cardiac mortality or MI.
With a PPV of 55.4% (95% CI: 46.2-64.6), the rule-in group comprised 15.4% (112/729). The NPV of the hs-cTnT HEART Pathway was 99.3% (95% CI: 98.3-100) in the validation cohort, with 37.6% (272/723) of cases ruled out, of which 2 experienced 30-day cardiac mortality or MI. 14.5 % (105 out of 723) of the sample fell into the rule-in category for a positive predictive value (PPV) of 57.1 % (95% CI: 47.7-66.6). Using successive 0- and 1-hour hs-cTnT measurements, the new hs-cTnT HEART Pathway has a high NPV and a modest PPV for predicting 30-day cardiac mortality or MI.