Validation of the No Objective Testing Rule and Comparison to the HEART Pathway

Abstract

Background

The No Objective Testing Rule (NOTR) is a decision aid designed to safely identify Emergency Department (ED) patients with chest pain who do not require objective testing for coronary artery disease.

Objectives

To validate the NOTR in a cohort of US ED patients with acute chest pain and compare its performance to the HEART Pathway.

Methods

A secondary analysis of 282 participants enrolled in the HEART Pathway Randomized Controlled Trial was conducted. Each patient was classified as low-risk or at- risk by the NOTR. Sensitivity for major adverse cardiac events (MACE) at 30 days was calculated in the entire study population. NOTR and HEART Pathways were compared among patients randomized to the HEART Pathway in the parent trial using McNemar's test and the net reclassification index (NRI).

Results

MACE occurred in 22/282 (7.8%) participants, including no deaths, 16/282 (5.6%) with MI, and 6/282 (2.1%) with coronary revascularization without MI. NOTR was 100% (95% CI 84.6-100%) sensitive for MACE and identified 78/282 patients (27.7%, 95% CI 22.5-33.3%) as low-risk. In the HEART Pathway arm (n=141), both NOTR and HEART Pathway identified all patients with MACE as at-risk. Compared to NOTR, the HEART Pathway was able to correctly reclassify 27 patients without MACE as low-risk, yielding a NRI of 20.8% (95% CI 11.3-30.2%).

Conclusions

Within a US cohort of ED patients with chest pain, the NOTR and HEART Pathway were 100% sensitive for MACE at 30 days. However, the HEART Pathway identified more patients suitable for early discharge than the NOTR.

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