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ACES (Accelerated Chest Pain Evaluation With Stress Imaging) Protocols Eliminate Testing Disparities in Patients With Chest Pain

Miller, Chadwick D., MD, MS*; Stopyra, Jason P., MD*; Mahler, Simon A., MD, MS*; Case, L. Doug, PhD; Vasu, Sujethra, MD; Bell, Ronny A., PhD§,¶; Hundley, W. Gregory, MD

Critical Pathways in Cardiology: March 2019 - Volume 18 - Issue 1 - p 5–9
doi: 10.1097/HPC.0000000000000161
Original Articles
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Background: Patients from racial and ethnic minority groups presenting to the Emergency Department (ED) with chest pain experience lower odds of receiving stress testing compared with nonminorities. Studies have demonstrated that care pathways administered within the ED can reduce health disparities, but this has yet to be studied as a strategy to increase stress testing equity.

Methods: A secondary analysis from 3 randomized clinical trials involving ED patients with acute chest pain was performed to determine whether a care pathway, ACES (Accelerated Chest pain Evaluation with Stress imaging), reduces the racial disparity in index visit cardiac testing between African American (AA) and White patients. Three hundred thirty-four participants with symptoms and findings indicating intermediate to high risk for acute coronary syndrome were enrolled in 3 clinical trials. Major exclusions were ST-segment elevation, initial troponin elevation, and hemodynamic instability. Participants were randomly assigned to receive usual inpatient care, or ACES. The ACES care pathway includes placement in observation for serial cardiac markers, with an expectation for stress imaging. The primary outcome was index visit objective cardiac testing, compared among AA and White participants.

Results: AA participants represented 111/329 (34%) of the study population, 80/220 (36%) of the ACES group and 31/109 (28%) of the usual care group. In usual care, objective testing occurred less frequently among AA (22/31, 71%) than among White (69/78, 88%, P = 0.027) participants, primarily driven by cardiac catheterization (3% vs. 24%; P = 0.012). In ACES, testing rates did not differ by race [AA 78/80 (98%) vs. White 138/140 (99%); P = 0.623]. At 90 days, death, MI, and revascularization did not differ in either group between AA and White participants.

Conclusions: A care pathway with the expectation for stress imaging eliminates the racial disparity among AA and White participants with chest pain in the acquisition of index-visit cardiovascular testing.

From the *Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC

Department of Internal Medicine/Cardiology, Wake Forest School of Medicine, Winston-Salem, NC

Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC

§Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC

Maya Angelou Center for Health Equity, Wake Forest School of Medicine, Winston-Salem, NC.

Received for publication March 4, 2018; accepted June 24, 2018.

Author contributions to this study are as follows: study concept and design is done by C.D.M., S.A.M., and W.G.H. Acquisition of the data is performed by C.D.M., S.A.M., and W.G.H. Analysis and interpretation of the data is carried out by C.D.M., J.P.S., S.A.M., L.D.C., S.V., R.A.B., and W.G.H. Drafting of the manuscript is done by C.D.M., J.P.S., S.A.M., L.D.C., S.V., R.A.B., W.G.H. Critical revision of the manuscript for important intellectual content is carried out by C.D.M., J.P.S., S.A.M., L.D.C., S.V., R.A.B., and W.G.H. Statistical expertise is performed by L.D.C. and R.A.B. Acquisition of funding is carried out by C.D.M., S.A.M., and W.G.H.

Sponsor or funding source: Supported by National Institutes of Health grants R01 HL118263, R21 HL097131, R01 HL076438, R01 CA167821, R01 HL118740, and L30 HL120008, by American Heart Association, by Association of American Medical Colleges, and by The Donaghue Foundation.

C.D.M. declares having financial interest with Siemens, Cardioxyl Pharmaceuticals, Novartis, Radiometer, and Cardiorentis. J.P.S. declares having financial interest with Abbott. S.A.M. declares having financial interest with Siemens and Abbott. W.G.H. declares having financial interest with Bracco, Siemens, and Prova. The other authors declare no conflicts of interest.

Reprints: Jason P. Stopyra, MD, Department of Emergency Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157. E-mail: jstopyra@wakehealth.edu

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