Does the ACC pathway work for patients with chest pain?

The expert consensus decision pathway recently published by the American College of Cardiology (ACC) has demonstrated its safety and efficacy in people with chest pain participating in an observational cohort study. However, those with coronary artery disease (CAD) may not benefit from such strategy.

Study authors validated the ACC pathway in a multisite US cohort involving adults with possible acute coronary syndrome from five US emergency departments from 1 November 2020 to 31 July 2022. Patients were stratified according to the ACC pathway using electrocardiographs and 0- and 2-hour high-sensitivity troponin (Beckman Coulter) measures.

Thirty-day all-cause death or myocardial infarction (MI) served as the primary safety outcome. Efficacy was defined as the proportion of patients classified to the rule-out zone. The authors also assessed the negative predictive value for the primary outcome in the whole cohort and in a subgroup of patients with CAD (ie, prior MI, revascularization, or ≥70-percent coronary stenosis).

A total of 14,395 patients (median age 56 years) completed the ACC pathway assessments. Of these, 7,437 (51.7 percent) were women, while 3,386 (23.5 percent) had a CAD diagnosis and 1,168 (8.1 percent) had MI or died within 30 days.

The ACC pathway demonstrated a 48.1-percent (95 percent confidence interval [CI], 47.3‒49.0) efficacy. Twenty-two of 6,930 (0.3 percent) patients in the rule-out zone had death or MI at 30 days, generating a negative predictive value of 99.7 percent (95 percent CI, 99.5‒99.8).

Of the 3,386 patients who presented with CAD, 676 (20.0 percent) were stratified to the rule-out zone. However, 10 (1.5 percent) of the 676 patients either died or had MI within 30 days.