Early rule-out of major adverse cardiac events in acute chest pain patients using a risk score and self-reported computerised history taking

Abstract

Abstract Introduction Risk scores, such as the History, ECG, Age, Risk factors, and Troponin (HEART) score, Emergency Department Assessment of Chest Pain Score Accelerated Diagnostic Protocol (EDACS-ADP), and Troponin-only Manchester Acute Coronary Syndrome (T-MACS), are recommended for the evaluation of acute chest pain patients. Obtaining a structured medical history by self-reported computerised history taking (CHT) may provide an automated and improved risk assessment in the emergency department (ED). Purpose We aimed to determine the diagnostic accuracy of three well-established acute chest pain risk scores using CHT to predict 30-day major adverse cardiovascular event (MACE). Methods Prospective cohort of clinically stable patients aged ≥18 years presenting with a chief complaint of chest pain and an ECG not indicating an acute coronary syndrome (ACS), at a tertiary hospital ED during 2017–2019. Medical histories were self-reported on a tablet using a CHT program (Clinical Expert Operating System, CLEOS), owned by a public university. With >17,000 decision nodes, CLEOS mimics a physician interview and tailors each interview depending on previous answers. Data acquired is in a binary structured format and can be used for input in clinical decision support systems. The HEART score, EDACS-ADP, and T-MACS were calculated from the CHT and the electronic health records (EHR). Relevant EHR data, including medical history, vital signs, and lab data, was extracted manually by the research staff in a predetermined standardised way. The EHR was subsequently reviewed for ACS and intervention procedure International Classification of Diseases (ICD) codes for any 30-day 3-point MACE. Results Of the 1,000 consecutive participants enrolled (mean age 55±17 years; 54% women), the HEART score, EDACS-ADP, and T-MACS could be calculated in 65%, 65% and 68%, respectively using only CHT acquired data. Main reasons for premature termination of the CHT were early discharge from ED or getting tired. A 30-day MACE occurred in 7.2% of the total population. The sensitivity, specificity, positive and negative predictive values of any 30-day MACE are presented in Table 1. The diagnostic accuracy for each risk score using CHT was similar to previous studies, where physician-collected data was used. Conclusions CHT can provide relevant risk scores in a majority of acute chest pain patients, and allow a safe and early rule-out of a 30-day MACE. The use of CHT may enable automation and improve the management of a large proportion of low-risk acute chest pain patients in the ED.Example of a question in the CHT program