Background Identification of patients with acute coronary occlusion requiring emergent intervention remains a diagnostic challenge for emergency department (ED) physicians, with 25-50% of cardiac catheterization lab (CCL) activations resulting in no intervention. Our goal in this study was to determine whether a pathway incorporating artificial intelligence (AI)-based ECG interpretation could rapidly identify a subset of patients who do not have acute coronary occlusion and therefore did not require emergency CCL activation. Methods We retrospectively analyzed patients for whom the CCL was activated by the ED physician for suspected STEMI between 1/1/2020 to 12/31/2023. ECG tracings were analyzed by Queen of Hearts™ AI ECG model (PMcardio, Powerful Medical). Standard care and AI-guided pathways were assessed. The primary outcome was acute coronary occlusion defined by coronary angiography. Sensitivity and specificity of the two pathways for identification of acute coronary occlusion were compared using paired-data methods. Results We studied 495 encounters; median age was 63 (25th, 75th 56, 73) years, and 360/495 (73%) were male. Among 260 encounters with acute coronary occlusion, sensitivity was 98.1% (95% CI 95.6%-99.2%) for standard care and 95.4% (95% CI 92.1-97.3%) for AI-guided pathways (difference −2.7%, 95% CI -5.0 to −0.3%). Among 235 encounters without acute occlusion, specificity was 60.9% (95% CI 54.5-66.9%) for standard care and 76.2% (95% CI 70.3%-81.2%) for AI-guided pathways (difference 15.3%, 95% CI 10.3%-20.3%). Conclusion Among patients for whom the ED physician has initiated CCL activation, a pathway incorporating AI-based ECG interpretation increases specificity with a small decrease in sensitivity.

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: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 Timely reperfusion is critical in reducing mortality in ST-segment elevation myocardial infarction (STEMI). Although electrocardiography-guided cardiac catheterization laboratory (CCL) activation on the basis of first medical contact recognition improves system-level response, diagnostic uncertainty, particularly in atypical presentations, contributes to false positive activations (FPAs) and reperfusion delays. OBJECTIVES The aim of this study was to evaluate the diagnostic performance and operational impact of artificial intelligence (AI)-based electrocardiographic (ECG) analysis in real-world STEMI triage across a multicenter U.S. registry. METHODS A total of 1,032 patients with suspected STEMI who triggered emergent CCL activation at 3 geographically diverse percutaneous coronary intervention centers (January 2020 to May 2024) were retrospectively analyzed. Index electrocardiograms underwent standard triage and blinded retrospective AI ECG analysis (Queen of Hearts, PMcardio) trained to detect acute coronary occlusion and benign mimics. The reference standard was an angiographically confirmed culprit lesion with positive enzymes. Diagnostic accuracy, subgroup analyses, and FPA reclassification were compared. RESULTS Of 1,032 emergent CCL activations, 601 (58.2%) had confirmed STEMI. The AI ECG model outperformed standard triage, demonstrating higher index ECG sensitivity (553 of 601 [92.0%; 95% CI: 89.7%-94.1%] vs 427 of 601 [71.0%; 95% CI: 67.4%-74.6%]), reducing FPA rates (34 of 431 [7.9%; 95% CI: 6.4%-9.6%] vs 180 of 431 [41.8%; 95% CI: 38.9%-44.7%]), and improving specificity (431 of 531 [81.0%; 95% CI: 77.2%-84.5%] vs 154 of 531 [29.0%; 95% CI: 24.8%-33.4%]) (P < 0.001 for all). The AI ECG model's area under the receiver-operating characteristic curve was 0.94 (95% CI: 0.92-0.95), maintaining consistent performance across clinically challenging subgroups (eg, atrial fibrillation, bundle branch block, STEMI equivalents). The AI ECG model reclassified 277 of 306 (91%) biomarkernegative FPAs correctly. CONCLUSIONS AI-based ECG analysis significantly improved STEMI detection, reduced FPAs, and enhanced the recognition of nonconventional presentations. This supports integration of AI-based ECG analysis into acute chest pain pathways. (c) 2026 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY license

Cardiac arrest is common and deadly, affecting up to 700 000 people in the United States annually. Advanced cardiac life support measures are commonly employed to improve outcomes. This 2025 guideline on adult post-cardiac arrest care from the American Heart Association summarizes the most recent published evidence for and recommendations on several important areas of post-cardiac arrest management. Based on structured evidence reviews, guidelines are provided for initial blood pressure, oxygen, ventilation, and glucose goals. Evidence evaluating the routine use of antibiotics after return of spontaneous circulation is reviewed. The update also reviews diagnostic testing modalities, temperature control goals and duration, and the use of percutaneous coronary intervention and mechanical circulatory support in the patient resuscitated from cardiac arrest. New data regarding the detection and management of seizures have been incorporated, along with updates regarding the timing and modalities used in neuroprognostication. These guidelines now differentiate prognostication for favorable versus unfavorable outcome. New sections on the utility of advanced neuromonitoring, along with definitions and treatment options for myoclonus, are included to guide the clinician. Expanded recommendations regarding how to optimize survivorship for patients, caregivers, and rescuers are reviewed. Finally, the potential role of organ donation in the patient resuscitated from cardiac arrest is reviewed.

BACKGROUND:Patient experience surveys are used to evaluate emergency physician (EP) performance, but they may be subject to gender bias. This study aimed to quantify the impact of EP gender on (1) the use of communal and agentic descriptors in free-text comments and (2) quantitative scores on patient experience surveys. METHODS:This retrospective study was conducted in a single urban, academic tertiary care emergency department (ED) that serves a diverse patient population. We included surveys for patients discharged from the ED during 1/1/19-12/31/21. Primary outcomes were the use of positive communal and agentic descriptors of the EP in the free-text portions of the patient experience surveys. Secondary outcome was mean quantitative physician score. Analyses included descriptive statistics and bivariate analyses, as well as a mixed effects model adjusted for patient and physician demographics and ED length of stay. RESULTS:We studied 883 encounters (501 [57 %] female patients) with applicable free-text comments in the patient experience surveys. In a multivariable mixed effects model adjusted for patient, physician, and operational variables, all-women, all-men, and mixed gender physician teams were equally likely to be described by positive communal terms and positive agentic terms. We also studied 3707 encounters (2077 [56 %] female patients) with quantitative physician scores available in the patient experience surveys. In a similar multivariable mixed effects model, physician gender was not associated with differences in mean physician scores. The median age in the larger cohort was 50 (IQR 26-64), and older patient age was associated with higher quantitative scores (p = 0.004). CONCLUSION:Among ED patients, physician gender was not associated with the language used to describe physicians or the quantitative scores assigned to them.

BACKGROUND:Growth differentiation factor-15 (GDF-15) is a novel biomarker of cardiac stress. GDF-15 may be a stronger predictor of all-cause death in patients with acute chest pain than traditional biomarkers such as high-sensitivity troponin T and BNP (B-type natriuretic peptide). However, data from US populations are lacking. Our objective was to determine whether GDF-15 is an independent predictor of all-cause death or acute myocardial infarction (AMI) at index visit, 30 days, and 90 days. METHODS:We conducted a secondary analysis of the STOP-CP (High Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification) trial, which prospectively enrolled adults (aged ≥21 years) from 8 US emergency departments with suspected AMI in 2017 to 2018. High-sensitivity troponin T, BNP, and GDF-15 assays were performed at a central laboratory on samples from baseline and 3 hours later. The primary outcome was the composite of all-cause death or AMI at index visit, 30 days, and 90 days. Multiple logistic regression models assessed the association between GDF-15 and all-cause death or AMI at index visit, as well as at 30 and 90 days, while adjusting for age, sex, number of cardiac risk factors, ischemic ECG findings, high-sensitivity troponin T, and N-terminal pro-B-type natriuretic peptide. RESULTS:We studied 1428 patients; median age was 58 (interquartile range, 49-66) years and 353 (25%) had a history of coronary artery disease. The composite outcome of all-cause death or AMI occurred in 169 (12%) patients at index visit, an additional 21 (1.5%) at 30 days, and an additional 27 (1.9%) at 90 days. In multiple logistic regression models, GDF-15 was independently associated with all-cause death or AMI at 30 days (adjusted odds ratio per SD, 1.27 [95% CI, 1.06-1.54]) and 90 days (adjusted odds ratio R per SD, 1.55 [95% CI, 1.26-1.94]), but not during the index visit (adjusted odds ratio per SD, 1.00 [95% CI, 0.83-1.16]). CONCLUSIONS:Among adult emergency department patients with suspected AMI, GDF-15 was independently associated with subsequent 30-day and 90-day all-cause death or AMI. These data suggest a potential role for GDF-15 in short-term cardiac risk stratification in emergency department patients without AMI at index visit.

BACKGROUND:The diagnostic performance of the high-sensitivity troponin T (hs-cTnT) 0/2-h algorithm is unclear among U.S. emergency department (ED) patients with acute chest pain. METHODS:A preplanned subgroup analysis of the STOP-CP cohort study was conducted. Participants with 0- and 2-h hs-cTnT measures prospectively enrolled at eight U.S. EDs from January 2017 to September 2018 were stratified into rule-out, observation, and rule-in zones using the hs-cTnT 0/2-h algorithm alone and combined with the history, electrocardiogram, age, and risk factor (HEAR) score. The primary outcome was adjudicated 30-day cardiac death or myocardial infarction (CDMI). The sensitivity and negative predictive value (NPV) of the 0/2-h rule-out zone and specificity and positive predictive value (PPV) of the rule-in zone for 30-day CDMI were calculated. RESULTS:Of the 1307 patients accrued, 53.6% (700/1307) were male and 58.6% (762/1307) were White, with a mean ± SD age of 57.5 ± 12.7 years. At 30 days, CDMI occurred in 12.9% (168/1307) of participants. The 0/2-h algorithm ruled out 61.4% (802/1307) of patients. Among rule-out patients, 1.9% (15/802) experienced 30-day CDMI, resulting in a sensitivity of 91.1% (95% confidence interval [CI] 85.7%-94.9%) and NPV of 98.1% (95% CI 96.9%-98.9%). The 0/2-h algorithm ruled in 12.4% (162/1307) patients of whom 61.7% (100/162) experienced 30-day CDMI. The rule-in zone specificity was 94.6% (95% CI 93.1%-95.8%) and PPV was 61.7% (95% CI 53.8%-69.2%) for 30-day CDMI. The 0/2-h algorithm combined with HEAR score ruled out 30.7% (401/1307) of patients with a sensitivity and NPV for 30-day CDMI of 98.2% (95% CI 94.9%-99.6%) and 99.3% (95% CI 97.8%-99.8%), respectively. CONCLUSIONS:The hs-cTnT 0/2-h algorithm ruled out most patients. With NPV of <99% for 30-day CDMI, the hs-cTnT 0/2-h algorithm, many emergency physicians may not consider it safe to use for U.S. ED patients. When combined with a low-risk HEAR score, NPV was >99% for 30-day CDMI at the cost of reduced efficacy.

• The decision to seek care by patients with symptoms suggesting acute coronary syndromes may be delayed, especially if chest pain and shortness of breath are not present. • Acute ischemic changes were clearly identified on a widely available smartwatch single‑lead electrocardiogram within minutes of symptoms onset. • Alerts focused on acute coronary syndromes identified by wearable devices may prompt immediate medical evaluation and opportunities for emergent therapies including reperfusion in patients.

Background: Women undergo diagnostic testing for pulmonary embolism (PE) in greater numbers than men, despite the disease incidence being higher in men overall. It is unknown if testing for PE varies based on patient chief complaint. Methods: This retrospective cohort study was conducted at two academic tertiary care hospitals. Nonpregnant adult patients (aged 18-49 years) were included if they presented to the ED between 1/1/2016 and 12/31/2018 with nontraumatic mechanisms and any of the following chief complaints: chest pain, shortness of breath, hemoptysis, or syncope AND had objective testing for PE. Data were obtained from the electronic medical record and analyzed descriptively. Four outcome variables were assessed: receipt of D-dimer testing, D-dimer positivity, receipt of pulmonary vascular imaging, and diagnosis of PE. Results: We studied 1,991 unique patient encounters, most of whom (63%; 1,256/1,991) were female. Overall, female patients had higher odds of receiving D-dimer testing than male patients (OR 1.30, CI 1.06-1.59, P = 0.015), while they had lower odds of being diagnosed with PE (OR 0.57, CI 0.36-0.90, P = 0.019). However, this trend varied by chief complaint. Among patients with chest pain, females had higher odds of having a D-dimer performed (OR 1.35, CI 1.01-1.80, P = 0.049) and lower odds of being diagnosed with PE (OR 0.36, CI 0.18-0.70, P = 0.003) than males. Conclusions: Both patient sex and chief complaint were associated with trends in diagnostic testing for PE. Among patients with chest pain, females are significantly more likely to be tested with a D-dimer and less likely to be diagnosed with PE.

Background: Delayed intervention for ST-segment elevation myocardial infarction (STEMI) is associated with higher mortality. The association of door-to-ECG (D2E) with clinical outcomes has not been directly explored in a contemporary US-based population. Methods: This was a three-year, 10-center, retrospective cohort study of ED-diagnosed patients with STEMI comparing mortality between those who received timely (<10 min) vs. untimely (>10 min) diagnostic ECG. Among survivors, we explored left ventricular ejection fraction (LVEF) dysfunction during the STEMI encounter and recovery upon post-discharge follow-up. Results: Mortality was lower among those who received a timely ECG where one-week mortality was 5% (21/420) vs. 10.2% (26/256) among those with untimely ECGs (p = 0.016), and in-hospital mortality was 6.0% (25/420) vs. 10.9% (28/256) (p = 0.028). Data to compare change in LVEF metrics were available in only 24% of patients during the STEMI encounter and 46.5% on discharge follow-up. Conclusions: D2E within 10 min may be associated with a 50% reduction in mortality among ED STEMI patients. LVEF dysfunction is the primary resultant morbidity among STEMI survivors but was infrequently assessed despite low LVEF being an indication for survival-improving therapy. It will be difficult to assess the impact of STEMI care interventions without more consistent LVEF assessment.

A single high-sensitivity troponin-T (hs-TnT) measurement may be sufficient to risk-stratify emergency department (ED) patients with possible acute coronary syndrome (ACS) using the recalibrated History, Electrocardiogram, Age, Risk Factors, Troponin (rHEART) score. We sought to validate this approach in a multiethnic population of United States patients and investigate gender-specific differences in performance. We conducted a secondary analysis of a prospective cohort study of adult ED patients with possible ACS at a single, urban, academic hospital. We investigated the diagnostic performance of rHEART for the incidence of type-1 acute myocardial infarction (AMI) and other major adverse cardiac events (MACE) at 30 days, using both single (19 ng/L) and gender-specific (14 ng/L for women, 22 ng/L for men) 99th percentile hs-TnT thresholds. The 821 patients included were 54% women, 57% Hispanic, and 26% Black. Overall, 4.6% of patients had MACE, including 2.4% with AMI. Single-threshold rHEART ≤3 had a sensitivity of 94.4% (95% confidence interval 81% to 99%) and negative predictive values of 99.3% (98% to 100%) for MACE; gender-specific thresholds performed nearly identically. Sensitivity and negative predictive values for AMI were 90.0% (67% to 98%) and 99.3% (97% to 100%). Excluding patients presenting <3 hours from symptom onset improved sensitivity for MACE and AMI to 97.0% (84% to 100%) and 94.1% (71% to 100%). Logistic regression demonstrated odds of MACE increased with higher rHEART scores at a similar rate for men and women. In conclusion, a single initial hs-TnT and rHEART score can be used to risk-stratify male and female ED patients with possible ACS, especially when drawn >3 hours after symptom onset.

INTRODUCTION:The History, Electrocardiogram, and Troponin (HET) score is a simplified alternative to the HEART score for risk stratifying emergency department (ED) patients with chest pain. This study evaluates the safety and efficacy of the HET score for 30-day cardiac death or myocardial infarction (MI). METHODS:We conducted a secondary analysis of the STOP-CP multisite cohort study. Risk score components were determined prospectively by the treating provider. Patients were classified into low-, intermediate-, and high-risk strata based on HEART and HET scores. Negative predictive value (NPV) was calculated for the primary safety outcome of cardiac death or MI at 30 days. Consistent with prior studies, the commonly accepted threshold of NPV ≥ 99 % was used to define safety. Efficacy was the proportion of patients classified as low risk. NPV and efficacy were compared between HET and HEART scores using generalized score statistic and McNemar's test, respectively. RESULTS:Among 1460 patients, 46.3 % (676/1460) were women and the mean age was 57.6 ± 12.8 years. Cardiac death or MI at 30 days occurred in 12.7 % (186/1460). Among patients with a low-risk HET score, 1.4 % (4/286) experienced 30-day cardiac death or MI, while 2.2 % (12/534) of patients with a low-risk HEART score had 30-day cardiac death or MI. This yielded a NPV for 30-day of 98.6 % (95 % CI 96.5-99.6 %) for the HET score vs 97.8 % (95 % CI 96.1-98.8 %) for the HEART score (p = 0.29).Efficacy of the HET score was 19.6 % (286/1460, 95 % CI 17.6-21.6 %) vs 36.6 % (534/1460, 95 % CI 34.1-39.1 %) for the HEART score (p < 0.001). CONCLUSION:In a multisite US cohort study, neither the HET score nor the HEART score achieved a safe NPV. The HET score had significantly lower efficacy than the HEART score. TRIAL REGISTRATION:High-Sensitivity Cardiac Troponin T to Optimize Chest Pain Risk Stratification (STOP-CP; ClinicalTrials.gov: NCT02984436; https://clinicaltrials.gov/ct2/show/NCT02984436).

BACKGROUND:Data comparing the performance of sex-specific to overall (non-sex-specific) high-sensitivity cardiac troponin (hs-cTn) cut-points for diagnosing acute coronary syndrome (ACS) are limited. This study aims to compare the safety and efficacy of sex-specific versus overall 99th percentile high-sensitivity cardiac troponin T (hs-cTnT) cut-points. METHODS:We conducted a secondary analysis of the STOP-CP cohort, which prospectively enrolled emergency department patients ≥ 21 years old with symptoms suggestive of ACS without ST-elevation on initial electrocardiogram across eight U.S. sites (January 25, 2017-September 6, 2018). Participants with both 0- and 1-h hs-cTnT measures less than or equal to the 99th percentile (sex-specific 22 ng/L for males, 14 ng/L for females; overall 19 ng/L) were classified into the rule-out group. The safety outcome was adjudicated cardiac death or myocardial infarction (MI) at 30 days. Efficacy was defined as the proportion classified to the rule-out group. McNemar's test and a generalized score statistic were used to compare rule-out and 30-day cardiac death or MI rates between strategies. Net reclassification improvement (NRI) index was used to further compare performance. RESULTS:This analysis included 1430 patients, of whom 45.8% (655/1430) were female; the mean ± SD age was 57.6 ± 12.8 years. At 30 days, cardiac death or MI occurred in 12.8% (183/1430). The rule-out rate was lower using sex-specific versus overall cut-points (70.6% [1010/1430] vs. 72.5% [1037/1430]; p = 0.003). Among rule-out patients, the 30-day cardiac death or MI rates were similar for sex-specific (2.4% [24/1010]) vs. overall (2.3% [24/1037]) strategies (p = 0.79). Among patients with cardiac death or MI, sex-specific versus overall cut-points correctly reclassified three females and incorrectly reclassified three males. The sex-specific strategy resulted in a net of 27 patients being incorrectly reclassified into the rule-in group. This led to an NRI of -2.2% (95% CI -5.1% to 0.8%). CONCLUSIONS:Sex-specific hs-cTnT cut-points resulted in fewer patients being ruled out without an improvement in safety compared to the overall cut-point strategy.

Cardiac arrest is common and deadly, affecting up to 700 000 people in the United States annually. Advanced cardiac life support measures are commonly used to improve outcomes. This “2023 American Heart Association Focused Update on Adult Advanced Cardiovascular Life Support” summarizes the most recent published evidence for and recommendations on the use of medications, temperature management, percutaneous coronary angiography, extracorporeal cardiopulmonary resuscitation, and seizure management in this population. We discuss the lack of data in recent cardiac arrest literature that limits our ability to evaluate diversity, equity, and inclusion in this population. Last, we consider how the cardiac arrest population may make up an important pool of organ donors for those awaiting organ transplantation.

Background: The European Society of Cardiology (ESC) 0/1-h high sensitivity troponin T (hs-cTnT) algorithm does not differentiate risk based on known coronary artery disease (CAD: prior myocardial infarction [MI], coronary revascularization, or >= 70% coronary stenosis). We recently evaluated its performance among patients with known CAD at 30-days, but little is known about its longer-term risk prediction. The objective of this study is to determine and compare the performance of the algorithm at 90-days among patients with and without known CAD. Methods: We performed a pre-planned subgroup analysis of the STOP-CP cohort, which prospectively enrolled ED patients >= 21 years old with symptoms suggestive of ACS without ST-elevation on initial ECG across 8 US sites (1/25/2017-9/6/2018). Participants with 0- and 1-h hs-cTnT measures (Roche, Basel, Switzerland) were stratified into rule-out, observe, and rule-in groups using the ESC 0/1-h algorithm. Algorithm performance was tested among patients with or without known CAD, as determined by the treating provider. The primary outcome was cardiac death or MI at 90-days. Fisher's exact tests were used to compare 90-day event and rule-out rates between patients with and without known CAD. Negative predictive values (NPVs) for 90-day cardiac death or MI with exact 95% confidence intervals were calculated and compared using Fisher's exact test. Results: The STOP-CP study accrued 1430 patients, of which 31.4% (449/1430) had known CAD. Cardiac death or MI at 90 days was more common in patients with known CAD than in those without [21.2% (95/449) vs. 10.0% (98/981); p < 0.001]. Using the ESC 0/1-h algorithm, 39.6% (178/449) of patients with known CAD and 66.1% (648/981) of patients without known CAD were ruled-out (p < 0.001). Among rule-out patients, 90-day cardiac death or MI occurred in 3.4% (6/178) of patients with known CAD and 1.2% (8/648) without known CAD (p = 0.09). NPV for 90-day cardiac death or MI was 96.6% (95%CI 92.8-98.8) among patients with known CAD and 98.8% (95%CI 97.6-99.5) in patients without known CAD (p = 0.09). Conclusion: Patients with known CAD who were ruled-out using the ESC 0/1-h hs-cTnT algorithm had a high rate of missed 90-day cardiac events, suggesting that the ESC 0/1-h hs-cTnT algorithm may not be safe for use among patients with known CAD. (c) 2024 Elsevier Inc. All rights reserved.