Performance of Coronary Risk Scores for Chest Pain

Study Questions:

What is the comparative accuracy of the EDACS (Emergency Department Assessment of Chest pain Score) (original and simplified) and modified HEART (History, Electrocardiogram, Age, Risk factors and Troponin) risk scores when using cardiac troponin I (cTnI) cutoffs below the 99th percentile, and precise major adverse cardiac event (MACE) risk estimates?

Methods:

The investigators conducted a retrospective study of adult emergency department (ED) patients evaluated for possible acute coronary syndrome (ACS) in an integrated healthcare system between 2013 and 2015. Negative predictive values (NPVs) for MACE (composite of myocardial infarction, cardiogenic shock, cardiac arrest, and all-cause mortality) were determined at 60 days. Reclassification analyses were used to assess the comparative accuracy of risk scores and lower cTnI cutoffs. To quantitatively summarize differences in accuracy amongst the three risk scores, as well as between alternative cTnI thresholds, the authors reported the net increase in true positives (patients with a MACE reclassified as non-low risk) and the net increase in false positives (patients without a MACE reclassified as non-low risk) as a proportion (net increase in true positives over the sum of the net increase in both true and false positives).

Results:

A total of 118,822 patients with possible ACS were included. The three risk scores’ accuracies were optimized using the lower limit of cTnI quantitation (<0.02 ng/ml) to define low risk for 60-day MACE, with reclassification yields ranging between 3.4% and 3.9%, while maintaining similar NPVs (range 99.49-99.55%, p = 0.27). The original EDACS identified the largest proportion of patients as low risk (60.6%, p < 0.0001).

Conclusions:

The authors concluded that among ED patients with possible ACS, the modified HEART score, original EDACS, and simplified EDACS all predicted a low risk of MACE with improved accuracy using a cTnI cutoff below the 99th percentile.

Perspective:

This retrospective study of patients with possible ACS following an ED evaluation reports that the accuracy of a low-risk classification for 60-day MACE by three risk scores (modified HEART, original EDACS, simplified EDACS) was optimized using a cTnI concentration threshold of <0.02 ng/ml (lower limit of quantitation). Furthermore, among the three risk scores, the original EDACS classified the greatest proportion of patients as low risk and performed similarly when compared to either the modified HEART score or the simplified EDACS in terms of accuracy. It seems that in terms of optimizing resource utilization, the original EDACS may be the preferred single risk score since it classified the greatest proportion of patients as low risk. Additional large prospective studies are indicated to confirm the safety of ED discharge with deferred cardiac testing among low-risk subgroups.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Implantable Devices, SCD/Ventricular Arrhythmias, Acute Heart Failure

Keywords: Acute Coronary Syndrome, Chest Pain, Diagnostic Imaging, Electrocardiography, Emergency Service, Hospital, Heart Arrest, Myocardial Infarction, Myocardial Ischemia, Patient Discharge, Risk Factors, Shock, Cardiogenic, Troponin I


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