OBJECTIVES:Chest pain is the most common reason for 9-1-1 calls in the United States. Triage of these patients to a local hospital vs tertiary care facility can be challenging. Our objective was to determine whether a cardiovascular telehealth program that connects rural paramedics with emergency physicians could avoid interfacility transfers in patients with chest pain. METHODS:We conducted a pilot prospective cohort study of adult patients with chest pain who underwent prehospital telehealth evaluation in a single emergency medical services (EMS) system (2/2021-11/2023). A paramedic completed a structured assessment of each patient, then connected with an emergency physician to complete a telehealth call. The physician reviewed the patient's electrocardgram (ECG), discussed the case with the paramedic, and met with the patient to determine risk for emergent conditions. Transport destination was guided by the following framework: local clinic (during operating hours) for stable low-risk patients, local community hospital for stable moderate-risk patients, and tertiary care center for high-risk patients, an ischemic ECG, or instability. The primary outcome was avoided interfacility transfers. Secondary outcomes included transport destination, avoided emergency department (ED) visits, and patient satisfaction assessed with the Short Assessment of Patient Satisfaction (SAPS) score. RESULTS:During the study, 112 patients were accrued, of which 45.5% (51/112) were female and 9.8% (11/112) were non-white with a mean age of 60 ± 17 years. Among these patients, 67.8% (76/112) were triaged to the local hospital, 19.6% (22/112) to a tertiary care center, 2.7% (3/112) to the clinic, and 9.8% (11/112) refused transport. Telehealth triage resulted in in 9 out of 112 patients (8.0%; 95% CI 5.0-13.0%) adjudicated as likely to have avoided subsequent interfacility transfer and avoided ED visits in 2 out of 112 patients (1.8%, 95% CI 0.0-4.3%). Mean SAPS score was 23.4 (±2.8), consistent with strong overall satisfaction with telehealth calls. CONCLUSIONS:Among rural patients with chest pain, an EMS telehealth program was associated with avoided interfacility transfers and strong patient satisfaction.

BACKGROUND:Ruling out myocardial infarction (MI) in patients with an initial indeterminate (detectable to mildly elevated) troponin measure is challenging. Myocardial-Ischaemic-Injury Index (MI3) is a machine-learning algorithm designed to diagnose MI, but its utility in patients with indeterminate troponins is unclear. This study seeks to evaluate its diagnostic performance in patients with an initial indeterminate troponin. METHODS:We conducted a secondary analysis of a cohort (Cardiovascular Magnetic Resonance-Invasive-based Strategies in Patients with Chest Pain and Detectable to Mildly Elevated Serum Troponin) of adult patients with symptoms suggestive of acute coronary syndrome and an initial clinical contemporary troponin of 0.006-1.0 ng/mL across four US hospitals. Patients with initial and 3-hour high-sensitivity cardiac troponin I (Abbott Laboratories) measures were classified by MI3 into low-risk, intermediate-risk and high-risk groups. The primary outcome was adjudicated MI at 30 days. The sensitivity, specificity and negative likelihood ratio (-LR) of MI3 for MI at 30 days were calculated and reported with 95% CIs. A receiver operator characteristics curve for MI at 30 days was created and area under the curve (AUC) for MI3 was calculated. RESULTS:Among 207 patients, 34.3% (71/207) were female with a mean age of 61±11 years. MI at 30 days occurred in 43.5% (90/207). The AUC for MI3 for the detection of MI at 30 days was 0.882 (95% CI 0.833 to 0.932). MI3 classified 34.8% (72/207) of patients as low-risk, of which 8.3% (6/72) had MI at 30 days, yielding a sensitivity of 93.3% (95% CI 86.1 to 97.5%) and -LR of 0.12 (95% CI 0.05 to 0.26). Among the 47.3% (98/207) classified as intermediate-risk, MI at 30 days occurred in 48.0% (47/98). MI3 classified 17.9% (37/207) as high-risk, among which 100% (37/37) had MI at 30 days, yielding a specificity of 100% (95% CI 96.9% to 100%). CONCLUSIONS:Among emergency department patients with an initial indeterminate troponin measure, the MI3 machine-learning algorithm had high AUC and specificity for 30-day MI.

BACKGROUND:Emergency Medical Services (EMS) patients with chest pain are often suspected of having non-ST-elevation acute coronary syndrome (NSTE-ACS). Current risk stratification protocols for NSTE-ACS have limitations, leading to a lack of a well-organised prehospital diagnostic pathway. Recent studies have demonstrated that using clinical risk scores (CRS) including point-of-care (POC)-troponin in the EMS can improve prehospital diagnostic pathways for suspected NSTE-ACS. The primary aim of this systematic review and individual patient data meta-analysis was to assess safety of low-risk stratification for suspected NSTE-ACS patients in the prehospital setting. METHODS:Prospective studies using CRS or POC-troponin for risk stratification in suspected NSTE-ACS patients within the EMS setting were included. Safety was assessed using sensitivity and negative predictive value (NPV) for patients identified as low risk, based on CRS or POC-troponin measurement, for three different endpoints within 30 days: (1) all-cause mortality, (2) composite of mortality and/or acute myocardial infarction (AMI), (3) major adverse cardiac events (MACE). RESULTS:Of 1526 articles screened, 6 were included, comprising 5.239 patients, and all utilised CRS derived from the History, ECG, Age, Risk-factor and Troponin (HEART) score. The summary of low-risk CRS diagnostic performance predicted all-cause mortality with a sensitivity of 93.2% (83.5-98.1) and NPV of 99.8% (99.5-99.9); mortality and/or AMI with a sensitivity of 91.8% (83.0-96.2) and an NPV of 97.3% (89.9-99.3); and MACE with a sensitivity of 92.8% (88.7-95.5) and an NPV of 97.2% (92.1-99.0). Lowering the CRS cut-off value for identifying low-risk patients increased sensitivity and NPV but decreased the proportion of patients classified as low risk. CONCLUSION:In well-trained EMS systems, where prompt and accurate follow-up of low-risk patients is possible, HEART-derived CRS effectively identify patients with a very low risk of 30-day mortality and MACE. However, implementation in other healthcare systems requires additional validation, given the variations in healthcare structure, risk stratification processes and follow-up capabilities.

BackgroundColorectal cancer (CRC) incidence and mortality rates continue to be elevated even though effective screening methods are widely available. To increase CRC screening in primary care practices, our team developed a tablet-based digital health program (mPATH) designed to identify patients needing CRC screening, provide education, and empower patients to request a screening test via the program. ObjectiveThis study aimed to qualitatively assess facilitators of and barriers to implementing and maintaining mPATH in primary care clinics. MethodsIn a pragmatic implementation trial, clinics were randomized to receive only in-person training and technological support via phone or email (low touch) or added levels of support, such as at-elbow support during launch, regular check-ins, memos, and reports (high touch). After implementation and data collection were concluded, we conducted telephone interviews with health care providers, clinic managers, and front desk and nursing staff recruited from 8 primary care clinics of varying sizes and with varying degrees of implementation of mPATH. The interviews were designed to collect perceived facilitators of and barriers to using mPATH. All interviews were administered via telephone by a single project staff member with no prior contact with participants. Interviews were audio-recorded, and 2 study team members independently coded each interview transcript and developed a codebook to identify meaningful categories in the dataset. The coders met periodically to resolve discrepancies. Data within each category were abstracted and synthesized into themes. Themes were determined inductively by prevalence and salience in the data per the principles of thematic analysis. ResultsA total of 33 interviews were completed between September 2021 and April 2023 with health care providers (n=8, 24.2%), clinic managers (n=9, 27.3%), nursing staff (n=8, 24.2%), and front desk staff (n=8, 24.2%). Interviews averaged 26.7 (SD 4.9) minutes. Barriers and facilitators identified varied among clinic sites and by clinic role. Overall, the primary factors supporting the implementation of mPATH were health care provider and staff buy-in, perceived potential time savings, and workflow improvement. The primary barriers identified were perceived lack of need for the program and technical issues. There was no significant indication that clinic size or randomization to low- or high-touch training and support played a role in the decision to continue or stop using the program. ConclusionsImplementation of a tablet-based CRC screening tool in primary care practices is feasible with health care provider and staff buy-in and validation of potential time savings and workflow improvements but may be limited by perceived lack of need for the program and technical issues.

The high-sensitivity History, Electrocardiogram (ECG), Age, Risk factor, and Troponin (HEART) Pathway (hs-HP) includes a "one-and-done" strategy where patients with a non-ischemic ECG, no known coronary artery disease, HEAR score ≤3, and chest pain duration >3 hours can be discharged with a single very-low high-sensitivity troponin (hs-cTnI) measure <4 ng/L. We aimed to evaluate the safety and effectiveness of this "one-and-done" hs-cTn strategy using a multisite emergency department cohort of patients with acute chest pain (N=12,190). Among these, 13.4% (1,628/12,190) were eligible for the one-and-done strategy, of which 89.6% (1,459/1,628) were discharged from the ED and 0.2% (3/1,628) had all-cause mortality or myocardial infarction at 30 days. Thus, the one-and-done strategy was safe and effective.

BACKGROUND:Engaging community stakeholders in clinical trials planning identifies participation barriers and facilitators to support future trial success. We assessed interest and perceived capacity of the National Cancer Institute Community Oncology Research Program (NCORP) practices and engaged stakeholders to inform a future multisite clinical trial involving caregivers. METHODS:A cross-sectional survey of NCORP practices (WF-2300CD) assessed interest (somewhat or very likely to participate) and capacity (ie, criteria: ≥5 eligible dyad accruals per quarter, identification of necessary study implementers) and barriers and facilitators to participating in a future cancer caregiver-focused trial. Interest and capacity were estimated with 95% confidence intervals (CIs), and logistic regression was used to identify statistically significant predictors. Free-text responses were analyzed using content analysis. RESULTS:Among 136 initial responding practices, 126 (92%) completed the survey (November 2023-April 2024), 56% saw at least 1000 new patient cases annually, 13.5% served at least 30% racial and ethnic minority patients, and 13.5% were designated critical access hospitals. Overall, 84.9% (95% CI = 77.5% to 90.1%) expressed interest in a caregiver-focused trial, but only 37.3% (95% CI = 28.9% to 46.4%) met all capacity criteria; capacity was the sole predictor of interest (adjusted odds ratio [OR] = 5.79, 95% CI = 1.23 to 27.13). Most (88.9%) practices estimated 5 or more eligible caregiver-patient dyads per quarter, but only 44.4% believed they could accrue that amount. Key participation barriers included staffing limitations and challenges related to eligibility and recruitment. Practices emphasized clear guidance on dyad eligibility, recruitment materials, workflow training, and resource considerations to improve trial participation. CONCLUSION:Early stakeholder engagement identified actionable barriers and produced practice-aligned strategies to enhance caregiver trial participation in community oncology settings. Targeted capacity building may improve participation for future caregiver-focused trials.

Background Family caregivers of patients with lung cancer experience high levels of unmet needs, burden, and distress, yet systematic processes to identify and connect caregivers with resources are lacking in community oncology. The Caregiver Oncology Needs Evaluation Tool (CONNECT) is a hybrid intervention delivered through a combination of web-based components and telephone-based navigation to inform caregivers about resources, assess their needs, and connect them to tailored supportive care services. Initial pilot testing at a single academic center demonstrated feasibility and acceptability, but feasibility in community settings remains untested. In this study, we aim to assess the multi-site feasibility of CONNECT. Methods This multi-site, randomized controlled pilot trial (WF-2301CD) is conducted through the Wake Forest National Cancer Institute Community Oncology Research Program (NCORP) Research Base. Lung cancer caregiver-patient dyads (N = 120) are recruited from 12 community oncology practices and randomized to: CONNECT, generic resource list, or usual care. The primary objective is to assess multi-site feasibility, measured by caregiver retention at 12-weeks. Secondary objectives include evaluating caregiver accrual, participation, retention at 24-weeks, and acceptability, as well as process metrics. Exploratory objectives assess patient accrual, participation and retention. Data are collected via surveys at baseline, 12-, and 24-weeks, with additional process tracking by site staff and navigators. Discussion This trial will provide critical data on the multi-site feasibility of implementing CONNECT in community oncology practices to inform protocol and design refinements for a future efficacy trial. If feasible, future efficacy testing will focus on the impact of CONNECT on caregiver burden and distress.NCT06383988

BACKGROUND:New point-of-care (POC) high sensitivity troponin (hs-cTn) assays could improve chest pain care efficiency. This study seeks to determine whether implementation of POC hs-cTn reduces key Emergency Department (ED) time metrics. METHODS:A prospective cohort study was conducted at three U.S. EDs (February-September 2025). Adults without STEMI and at least one hs-cTnI ordered were accrued. Blood samples were collected simultaneously for POC hs-cTnI measurement on an i-STAT 1 analyzer (Abbott Laboratories) and central laboratory hs-cTnI measurement (Beckman Coulter). Following POC hs-cTn measures, providers were surveyed regarding potential disposition and treatment decisions which were compared to actual disposition times. Turnaround time, time-to-disposition, and ED length of stay for POC versus central laboratory measures were compared using Wilcoxon signed-rank tests. RESULTS:During the study period, 602 patients were accrued, of which 48% (286/602) were female and median age was 60 years (IQR: 50-70). POC hs-cTnI had a median turnaround time of 16 min (IQR: 15-17) compared to 52 min (IQR: 45-61) for the central laboratory, a 36-min difference (p < 0.001). Median time to potential disposition decision using POC was 222 min (IQR: 144-320) versus 273 min (IQR: 219-382) for central laboratory measures, a difference of 51 min (p < 0.001). The median potential ED length of stay was 325 min (IQR: 224-513) for POC versus 387 min (IQR: 276-564) for the central laboratory, yielding a potential reduction of 62 min (p < 0.001). CONCLUSIONS:POC hs-cTnI measurement reduced turnaround time and produced substantive potential reductions in time-to-disposition decision and ED length of stay. TRIAL REGISTRATION:NCT06899776.

Introduction Stereotactic body radiotherapy (SBRT) to peripheral lung tumors is associated with radiation-induced bone effects that may predispose patients to chest wall pain (CWP) and radiation-induced rib fractures (RIRF). These effects may be inhibited by bisphosphonates. We aimed to determine the impact of risedronate on the radiologic biomarker rib cortical thickness (CTh) in patients with peripheral lung tumors treated with SBRT. Methods This randomized, double-blind, placebo-controlled phase 2 clinical trial enrolled patients with tumors within 2 cm of the chest wall, who were randomized 1:1 to risedronate 150 mg prior to SBRT or placebo. CTh was evaluated every 3 months for 1 year. The primary endpoint was percent change in rib CTh from baseline to 3 months within the >30 Gy isodose region. Results 73 patients (78 tumors) were randomized and eligible for analysis. Baseline CTh was 1.46 (±0.34) mm and 1.44 (±0.42) mm in the placebo and risedronate arms, respectively. Mean percent change from baseline to 3 months within the 30 Gy isodose region was: 6.4% (±18.0) for placebo versus 3.1% (±17.9) for risedronate (absolute difference: -3.3%, p=0.44). The absolute difference in percent CTh change from baseline to 6, 9, and 12 months in the risedronate (versus placebo) group was -4.7%, -8.3%, and -11.8%, respectively. Conclusion In patients with peripheral lung tumors treated with SBRT, risedronate did not result in statistically significant differences in rib CTh within the 30 Gy isodose region. This biomarker of bone changes after SBRT demonstrated increases over time within higher dose regions in the placebo group but remained similar to baseline in the risedronate group. Further studies are needed

Background In rural settings, women with ST-elevation myocardial infarction (STEMI) are less likely to receive timely reperfusion than men. We explore factors that may impact time to reperfusion by sex for patients with STEMI. Methods We conducted a cohort study of adults with STEMI activations from 2016 to 2020 using regional North Carolina STEMI registry data, which included eight rural emergency medical services (EMS) agencies and three percutaneous coronary intervention (PCI) centres. The primary outcome was EMS first medical contact to PCI in ≤90 min. By sex, we evaluated prehospital time intervals (dispatch, response, time-to-ECG, catheterisation laboratory activation, on-scene, transport and total EMS) and door-to-balloon time with clustered Wilcoxon rank-sum tests. We also evaluated agency and patient factors associated with timely reperfusion using generalised estimating equations. Results Of the 365 patients included, 30.1% (110/365) were female with a mean age of 62.5±12.7. Fewer women received PCI within 90 min compared with men (43.6% vs 67.8%, p<0.001). Women also experienced significantly longer total EMS time (42.5 vs 40.0 min, p=0.049) and door-to-balloon time (48.5 vs 40.0 min, p=0.01). Other time intervals were similar. After adjustment, women without exertional symptoms, with diabetes or with hypercholesterolaemia had lower odds of timely reperfusion. Among men, lower odds of timely reperfusion were observed among those without pain, who had catheterisation lab activation between 17:00 and 07:00, who were older or who had farther transport. Conclusion In rural settings, women without exertional chest pain and those with comorbid conditions were less likely to have timely reperfusion. Women experienced significantly longer total EMS time and door-to-balloon time than men.

OBJECTIVES:A 0/2-h algorithm for the i-STAT point-of-care (POC) high sensitivity troponin I (hs-cTnI) assay was recently derived in Australia. The objective of this study was to validate and optimize the performance of the 0/2-h algorithm in a multisite U.S. Emergency Department (ED) cohort. METHODS:A prospective cohort study was conducted at three U.S. EDs (February-September 2025). Adults without STEMI and at least one hs-cTnI ordered were accrued. Blood samples were collected simultaneously for POC hs-cTnI measurement on an i-STAT 1 analyzer (Abbott Laboratories) and central laboratory hs-cTnI measurement (Beckman Coulter). The primary outcome was index myocardial infarction (MI), adjudicated by experts using clinical hs-cTnI measures. Diagnostic performance of the Australian 0/2-h algorithm was assessed by calculating negative and positive predictive values (NPV, PPV) with associated 95% confidence intervals. Efficacy, defined as the proportion of patients classified into the rule-out zone, was calculated. Algorithm optimization tested modified cut points to increase efficacy while maintaining NPV ≥ 99% and achieving PPV ≥ 65%. RESULTS:During the study period, 578 patients with complete 0/2-h algorithm assessments were accrued. These patients were 48% (279/578) female, 40% (233/578) non-White, with a median age of 60 years (IQR: 50-70). Index MI occurred in 7.4% (43/578). Algorithm efficacy was 54.8% (317/578) and 8.8% (51/578) were classified to the rule-in zone. Among patients ruled-out, the NPV was 99.4% (95% CI: 97.7%-99.9%). The rule-in zone was associated with a PPV of 62.7% (95% CI: 48.1%-75.9%). Among 36.3% (210/578) patients classified to the observation zone, 4.3% (9/210) had an adjudicated index MI. An optimized 0/2-h algorithm increased efficacy to 60.0% (347/578) while achieving an NPV of 99.4% (95% CI: 97.9%-99.9%) and PPV of 74.4% (95% CI: 58.8, 86.5%) for index MI. CONCLUSIONS:The original Australian and optimized 0/2-h algorithms for i-STAT POC hs-cTnI measurement had high NPV and efficacy in a multisite U.S. COHORT: TRIAL REGISTRATION:Trial Registration: NCT06899776.

BACKGROUND:Large studies examining sex-based differences in emergency department (ED) cardiovascular care are lacking. This analysis compared cardiovascular healthcare utilization and safety outcomes between women and men in a large U.S. cohort managed under a standardized high-sensitivity troponin (hs-cTn) pathway. METHODS:We conducted an observational study of ED patients ≥18 years old presenting with chest pain from 1/2021-12/2021 across 25 EDs. Sex was defined by the legal sex EHR variable. The primary safety outcome was 30-day all-cause death or myocardial infarction (MI). The primary healthcare utilization outcome was hospitalizations at 30 days. Secondary healthcare utilization outcomes included 30-day objective cardiac testing (OCT: stress testing, coronary computed tomography angiography, invasive coronary angiography). Outcomes were compared between sexes using chi-squared tests and logistic regression, where models adjusted for cardiovascular disease confounders and initial hs-cTn. RESULTS:Among 40,979 patients, 56.6% (23,188/40,979) were female with mean age 52. Death or MI at 30 days occurred in 2.4% (552/23,188) of women and 5.2% (917/17,791) of men (p < 0.001). After adjustment, women had lower odds of death or MI (aOR 0.65, 95% CI 0.57-0.74). Hospitalizations occurred in 30.2% (6998/23,188) of women compared to 36.0% (6411/17,791) of men (p < 0.001). OCT occurred in 14.9% (3452/23,188) of women and 19.6% (3488/17,791) of men (p < 0.001). With adjustment, women were hospitalized less (aOR 0.93, 95% CI 0.88-0.98) and underwent less OCT (aOR 0.93, 95% CI 0.87-0.98) at 30-days. CONCLUSION:In a large ED cohort of patients with chest pain, rates of death or MI, hospitalizations, and OCT at 30-days were lower in women compared to men.

OBJECTIVES:High sensitivity cardiac troponin (hs-cTn) measures are used in the emergency department (ED) to evaluate patients with acute chest pain. Prehospital hs-cTn measurement could facilitate earlier rule-out of myocardial infarction (MI). The objective of this study is to assess the performance of prehospital blood draw for hs-cTnI measure alone, in combination with hs-cTnI measured at ED arrival, and incorporating the Myocardial Ischemic Injury Index (MI3) machine learning algorithm to rule-out index MI. METHODS:We conducted a pilot prospective observational cohort study among adult emergency medical services (EMS) patients with acute, non-traumatic chest pain. Two third-service EMS agencies and two tertiary care EDs in North Carolina participated. Demographics and initial ECG findings were collected. Blood was obtained prehospital and on ED arrival for hs-cTnI measurement. The clinical outcome was adjudicated index visit MI. Efficacy (percentage of patients with index MI ruled-out) and negative predictive value (NPV) for index MI were determined for the following strategies: (1) a very-low single prehospital hs-cTnI, (2) serial hs-cTnI change (delta) at the prehospital and arrival timepoints, (3) MI3 incorporating prehospital hs-cTnI alone, and (4) MI3 incorporating prehospital and arrival hs-cTnI. RESULTS:Of the 75 patients enrolled, 53.3% (40/75) were women, 32.0% (24/75) were Black patients, and the mean age was 62.2 ± 15.7 years. Index MI occurred in 8.0% (6/75). Prehospital hs-cTnI below the limit of quantification (≤2.7 ng/L) had an efficacy of 46.7% (35/75) with an NPV of 100% (95%CI 90.0%-100%) for index MI. A prehospital and arrival hs-cTnI delta ≤3 had an efficacy of 84.3% (43/51) with an NPV of 97.7% (95%CI 87.7-99.9%) for index MI. The standard low-risk MI3 threshold <1.6 with a single prehospital hs-cTnI had an efficacy and NPV for index MI of 76.0% (57/75) and 96.5% (95%CI 87.9-99.6), respectively. Finally, the standard low-risk MI3 threshold incorporating both prehospital and arrival hs-cTnI had an efficacy of 70.6% (36/51) and NPV of 100% (95%CI 90.3-100%) for index MI. CONCLUSIONS:Strategies using prehospital blood for hs-cTnI measurement alone and MI3 with prehospital and arrival hs-cTnI safely identified a large percentage of patients for rule-out, warranting further investigation in a larger trial.

BACKGROUND:This study aims to determine if differences in age affect safety and healthcare utilization among patients with chest pain in a multisite US ED cohort, after accounting for comorbidities and high-sensitivity troponin (hs-cTn). METHODS:We conducted a multisite observational study using the Wake Forest Chest Pain Registry, which included patients ≥ 18 years old with chest pain across 25 EDs (01/01/2021 to 12/31/2021). Each site used an hs-cTn chest pain protocol. Patients were categorized as older (≥ 65 years), middle-aged (46-64 years), or young (18-45 years). The primary safety outcome was death or MI at 30 days. The primary healthcare utilization outcome was 30-day hospitalization. Multivariable logistic regression models assessed the association between age and outcomes, adjusting for sex, race, ethnicity, obesity, smoking, rurality, coronary disease, diabetes, hypertension, hyperlipidemia, insurance, site, and hs-cTn, with young patients as the reference. RESULTS:Among 40 979 patients, 25.1% were older, 39.7% middle-aged, and 35.2% young. At 30 days, death or MI occurred in 7.3% (750/10 298) of older, 3.8% (611/16 260) of middle-aged, and 0.8% (108/14 421) of young patients. After adjustment, death or MI at 30 days was more common among older (aOR 1.57, 95% CI 1.17-2.12) and middle-aged (aOR 1.57, 95% CI 1.22-2.02) patients. Hospitalization at 30 days occurred in 56.3% (5799/10 298) of older, 35.4% (5761/16 260) of middle-aged, and 12.8% (1849/14 421) of young patients. With adjustment, hospitalization remained more common among older (aOR 2.51, 95% CI 2.27-2.78) and middle-aged (aOR 1.93, 95% CI 1.80-2.07) patients. CONCLUSION:After adjusting for comorbidities and hs-cTn results, older adults had higher rates of death or MI and hospitalization at 30 days.

BACKGROUND: The High-STEACS (High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome) pathway risk stratifies emergency department patients with possible acute coronary syndrome. This study aims to determine if the High-STEACS hs-cTnT (high-sensitivity cardiac troponin T) pathway can achieve the ≥99% negative predictive value (NPV) safety threshold for 30-day cardiac death or myocardial infarction (CDMI) in a multisite US cohort of patients with and without known coronary artery disease (CAD). METHODS: A secondary analysis of the STOP-CP (High-Sensitivity Cardiac Troponin T [Gen 5 STAT Assay] to Optimize Chest Pain Risk Stratification) cohort, which enrolled adult emergency department patients with possible acute coronary syndrome at 8 US sites (January 25, 2017–September 6, 2018). Participants were classified into outpatient and admission dispositions using the High-STEACS hs-cTnT pathway. Known CAD was defined as prior MI, coronary revascularization, or ≥70% coronary stenosis. Outcomes included 30-day CDMI and efficacy, defined as the proportion identified for outpatient disposition. NPVs and negative likelihood ratios for 30-day CDMI were calculated. NPVs were compared between CAD subgroups using a Fisher exact test. RESULTS: Among 1351 patients, 53.2% (719/1351) were male, 31.4% (424/1351) had known CAD, and the mean age was 57.4±12.8 years. At 30 days, CDMI occurred in 13.8% (187/1351). High-STEACS classified 63.4% (857/1351) to outpatient disposition, of which 2.0% (17/857) had 30-day CDMI, corresponding to an NPV of 98.0% (95% CI, 96.8–98.8) and negative likelihood ratio of 0.13 (95% CI, 0.08–0.20). In patients with CAD, 46.9% (199/424) were classified to outpatient disposition, of which 4.0% (8/199) had 30-day CDMI. Among patients without CAD, 71.0% (658/927) were classified to outpatient disposition with 1.4% (9/658) having 30-day CDMI. The NPV for 30-day CDMI was 96.0% (95% CI, 92.2–98.2) in patients with CAD versus 98.6% (95% CI, 97.4–99.4) among patients without CAD ( P =0.04). The negative likelihood ratio for 30-day CDMI among patients with CAD was 0.16 (95% CI, 0.08–0.31) and 0.12 (95% CI, 0.06–0.22) among patients without CAD. CONCLUSIONS: The High-STEACS hs-cTnT pathway had high efficacy but was unable to achieve the ≥99% NPV safety threshold for 30-day CDMI. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02984436.

BACKGROUND:While percutaneous coronary intervention (PCI) reperfusion within 90 minutes of first medical contact (FMC) is indicated for ST-segment elevation myocardial infarction (STEMI), long transport times in rural areas can make this unlikely. We sought to quantify Southeast US residents at risk of treatment delay due to transport. METHODS:A cross-sectional study of Southeast US residents was conducted using American Community Survey data and geographic information systems (GIS) to estimate emergency medical services (EMS) transport times to primary PCI (PPCI) centers. All PPCI centers in the study area were included, as well as centers in surrounding states. The main outcomes were the number of residents residing more than 30 and 60 minutes from PPCI. These cutoffs are based on national median EMS scene times and door-to-device times and correspond to estimated FMC-to-device times of 90 and 120 minutes, respectively. A secondary outcome was identification of counties with greater than 50% and 90% of their population at risk of treatment delay. RESULTS:Of 62,880,528 residents in the study area, we identified nearly 11 million at risk of delayed PCI (17.3%, 10,866,710 ± 58,143). Of those, 1,271,522 (± 51,858) live greater than 60 minutes from PPCI. We found that 8.4% (52/616) of counties have more than 50% of their population at risk of treatment delay. 42.3% (22/52) of those have more than 90% of at risk. CONCLUSIONS:Nearly 11 million people in the Southeast US do not have timely access to PCI. This disparity may contribute to increased morbidity and mortality.

BACKGROUND:Thirty-day performance of the high-sensitivity troponin T (hs-cTnT) European Society of Cardiology 0/1-hour (ESC 0/1-h) and "one-and-done" (hs-cTnT<limit of quantification) strategies are established. However, 90-day performance is unclear. Our objective was to evaluate the 90-day performance of these hs-cTnT strategies in a US cohort. METHODS:A preplanned secondary analysis of a prospective multisite US cohort was conducted. Adults with chest pain were enrolled from 8 emergency departments (January 2017-September 2018). hs-cTnT measures (0- and 1-h) were used to classify patients by the ESC 0/1-h algorithm into rule-out, observation, and rule-in zones. Patients with 0-h measures <limit of quantification were considered ruled out by the one-and-done strategy. The primary outcome was adjudicated 90-day cardiac death or myocardial infarction (MI). Negative predictive value (NPV) for the primary endpoint and efficacy (proportion ruled out) were calculated for each strategy alone and in combination with the History, ECG, Age, Risk factor, and Troponin (HEART) score. RESULTS:Among 1462 patients with a mean age of 57.6 ± 12.9 years, 46.4% (678/1462) were female, and 14.0% (205/1462) had cardiac death or MI at 90 days. One-and-done strategy efficacy was 32.8% (479/1462), and NPV was 99.0% [95% confidence interval (CI), 97.6-99.7]. Adding the HEART score decreased efficacy to 20.1% (293/1462) and increased NPV to 99.7% (95% CI, 98.1-100). ESC 0/1-h efficacy was 57.8% (826/1430) and NPV was 98.3% (95% CI, 97.2-99.1). Combined with a HEART score, NPV increased to 99.3% (95% CI, 98.0-99.9), but efficacy decreased to 30.8% (95% CI, 28.3-33.2). CONCLUSIONS:The one-and-done strategy and ESC 0/1-hour algorithm had modest rates of missed 90-day cardiac death or MI. Adding a HEART score improved safety but decreased efficacy.

Background Identifying and eliminating health disparities is a public health priority. The goal of this analysis is to determine whether cardiac testing or outcome disparities exist by race or sex in patients with detectable to mildly elevated serum troponin. Methods We conducted a secondary analysis of the CMR-IMPACT trial that randomized patients with symptoms suggestive of acute coronary syndrome and a detectable or mildly elevated troponin measure from 4 US hospitals to an early invasive angiography or cardiac MRI strategy. The primary endpoint was the composite of all-cause mortality, myocardial infarction, cardiac hospital readmission, and repeat cardiac ED. Secondary outcomes were components of the composite and revascularization. Results Participants (n = 312, mean age 61 ± 11 years) were 36.2 % non-white and 40.1 % female. The composite outcome occurred in 63.7 % of non-white vs. 49.8 % of white patients (aHR 1.50, 95 % CI 1.08–2.09) and 53.6 % of female vs. 55.6 % of male patients (aHR 0.93, 95 % CI 0.68–1.28). Non-white (aHR 0.57, 95 % CI 0.35–0.92) patients had lower rates of revascularization also less median stenosis (p < 0.001) and stenosis >70 % (p < 0.001) during index cardiac testing. Despite these findings, ACS after discharge was higher among non-white patients (aHR 1.84, 95 % CI 1.11–3.05). Females had lower rates of revascularization (aHR 0.52, 95 % CI 0.33–0.82), but no increase in ACS after discharge (aHR 0.90, 95 % CI 0.55–1.49). Conclusion Non-white patients had higher rates of ACS following discharge despite lower rates of obstructive CAD following standardization of index cardiac testing. Future disparity works should explore care following the index encounter.