BACKGROUND:The HEART Pathway (History, Electrocardiogram, Age, Risk factors, Troponin) can be used with high-sensitivity cardiac troponin to risk stratify emergency department patients with possible acute coronary syndrome. However, data on whether a high-sensitivity HEART Pathway (hs-HP) are safe and effective is lacking.METHODS:An interrupted time series study was conducted at 5 North Carolina sites in 26 126 adult emergency department patients being investigated for possible acute coronary syndrome and without ST-segment–elevation myocardial infarction. Patients were accrued into 16-month preimplementation and postimplementation cohorts with a 6-month wash-in phase. Preimplementation (January 2019 to April 2020), the traditional HEART Pathway was used with 0- and 3-hour contemporary troponin measures (Siemens). In the postimplementation period (November 2020 to February 2022), a modified hs-HP was used with 0- and 2-hour high-sensitivity cardiac troponin (Beckman Coulter) measures. The primary safety and effectiveness outcomes were 30-day all-cause death or myocardial infarction and 30-day hospitalizations. These outcomes and early discharge rate (emergency department discharge without stress testing or coronary angiography) were determined from health records and death index data. Outcomes were compared preimplementation versus postimplementation using χ² tests and multivariable logistic regression to adjust for potential confounders.RESULTS:Preimplementation and postimplementation cohorts included 12 317 and 13 809 patients, respectively, of them 52.7% (13 767/26 126) were female with a median age of 54 years (interquartile range, 42–66). Rates of 30-day death or MI were 6.8% (945/13 809) postimplementation and 7.7% (948/12 317) preimplementation (adjusted odds ratio, 1.00 [95% CI, 0.90–1.11]). hs-HP implementation was associated with 19.9% (95% CI, 18.7%–21.1%) higher early discharges (post versus pre: 63.6% versus 43.7%; adjusted odds ratio, 2.22 [95% CI, 2.10–2.35]). The hs-HP was also associated with 16.1% (95% CI, 14.9%–17.3%) lower 30-day hospitalizations (postimplementation versus preimplementation, 31.4% versus 47.5%; adjusted odds ratio, 0.51 [95% CI, 0.48–0.54]). Among early discharge patients, death or myocardial infarction occurred in 0.5% (41/8780) postimplementation versus 0.4% (22/5383) preimplementation (P=0.61).CONCLUSIONS:hs-HP implementation is associated with increased early discharges without increasing adverse events. These findings support the use of a modified hs-HP to improve chest pain care.

中文翻译：

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高敏感性心肌肌钙蛋白 HEART 通路在可能患有急性冠状动脉综合征的患者中的安全性和有效性

背景：心脏通路（病史、心电图、年龄、危险因素、肌钙蛋白）可与高敏心肌肌钙蛋白一起使用，对可能患有急性冠状动脉综合征的急诊科患者进行风险分层。然而，关于高敏心脏通路 (hs-HP) 是否安全有效的数据尚缺乏。 方法：在北卡罗来纳州 5 个地点对 26 126 名接受可能急性冠心病调查的成人急诊患者进行了一项间断时间序列研究综合征且无​​ ST 段抬高型心肌梗死。患者被纳入为期 16 个月的实施前和实施后队列，并有 6 个月的洗入期。实施前（2019 年 1 月至 2020 年 4 月），传统的 HEART Pathway 与 0 小时和 3 小时当代肌钙蛋白测量（西门子）一起使用。在实施后期间（2020 年 11 月至 2022 年 2 月），使用改良的 hs-HP 进行 0 小时和 2 小时高灵敏度心肌肌钙蛋白 (Beckman Coulter) 测量。主要安全性和有效性结果是 30 天全因死亡或心肌梗死以及 30 天住院治疗。这些结果和早期出院率（急诊科出院，无需压力测试或冠状动脉造影）是根据健康记录和死亡指数数据确定的。使用^χ2检验和多变量逻辑回归对实施前和实施后的结果进行比较，以调整潜在的混杂因素。 结果：实施前和实施后队列分别包括 12 317 名和 13 809 名患者，其中 52.7% (13 767/26 126) 是女性中位年龄 54 岁（四分位数范围，42-66）。实施后 30 天死亡率或 MI 率为 6.8% (945/13 809)，实施前为 7.7% (948/12 317)（调整后的比值比，1.00 [95% CI，0.90–1.11]）。 hs-HP 实施与 19.9%（95% CI，18.7%–21.1%）较高的早期出院率相关（出院后与出院前：63.6% 与 43.7%；调整后的比值比，2.22 [95% CI，2.10-2.35]）。 hs-HP 还与 30 天住院率降低 16.1%（95% CI，14.9%–17.3%）相关（实施后与实施前，31.4% 与 47.5%；调整后比值比，0.51 [95% CI，0.48–0.54] ]）。在早期出院患者中，实施后死亡或心肌梗死发生率为 0.5% (41/8780)，而实施前为 0.4% (22/5383) ( P =0.61)。 结论：hs-HP 实施与早期出院率增加相关，但不增加不良事件。这些发现支持使用改良的 hs-HP 来改善胸痛护理。