Comparison of clinical risk scores for triaging high-risk chest pain patients at the emergency department.
Acute Coronary Syndrome
/ diagnosis
Adult
Aged
Chest Pain
/ diagnosis
Emergency Medical Services
/ methods
Emergency Service, Hospital
Female
Humans
Male
Middle Aged
Pennsylvania
/ epidemiology
ROC Curve
Retrospective Studies
Risk Assessment
/ methods
Symptom Assessment
/ methods
Time Factors
Triage
/ methods
Acute coronary syndrome
Chest pain
HEART
TIMI
Journal
The American journal of emergency medicine
ISSN: 1532-8171
Titre abrégé: Am J Emerg Med
Pays: United States
ID NLM: 8309942
Informations de publication
Date de publication:
03 2019
03 2019
Historique:
received:
28
03
2018
revised:
10
05
2018
accepted:
07
06
2018
pubmed:
17
6
2018
medline:
12
11
2019
entrez:
17
6
2018
Statut:
ppublish
Résumé
Many of the clinical risk scores routinely used for chest pain assessment have not been validated in patients at high risk for acute coronary syndrome (ACS). We performed an independent comparison of HEART, TIMI, GRACE, FRISC, and PURSUIT scores for identifying chest pain due to ACS and for predicting 30-day death or re-infarction in patients arriving through Emergency Medical Services (EMS). We enrolled consecutive EMS patients evaluated for chest pain at three emergency departments. A reviewer blinded to outcome data retrospectively reviewed patient charts to compute each risk score. The primary outcome was ACS diagnosed during the primary admission, and the secondary outcome was death or re-infarction within 30-days of initial presentation. Our sample included 750 patients (aged 59 ± 17 years, 42% female), of whom 115 (15.3%) had ACS and 33 (4.4%) had 30-day death or re-infarction. The c-statistics of HEART, TIMI, GRACE, FRISC, and PURSUIT for identifying ACS were 0.87, 0.86, 0.73, 0.84, and 0.79, respectively, and for predicting 30-day death or re-infarction were 0.70, 0.73, 0.72, 0.72, and 0.62, respectively. Sensitivity/negative predictive value of HEART ≥ 4 and TIMI ≥ 3 for ACS detection were 0.94/0.98 and 0.87/0.97, respectively. In chest pain patients admitted through EMS, HEART and TIMI outperform other scores for identifying chest pain due to ACS. Although both have similar negative predictive value, HEART has better sensitivity and lower rate of false negative results, thus it can be used preferentially over TIMI in the initial triage of this population.
Sections du résumé
BACKGROUND
Many of the clinical risk scores routinely used for chest pain assessment have not been validated in patients at high risk for acute coronary syndrome (ACS). We performed an independent comparison of HEART, TIMI, GRACE, FRISC, and PURSUIT scores for identifying chest pain due to ACS and for predicting 30-day death or re-infarction in patients arriving through Emergency Medical Services (EMS).
METHODS AND RESULTS
We enrolled consecutive EMS patients evaluated for chest pain at three emergency departments. A reviewer blinded to outcome data retrospectively reviewed patient charts to compute each risk score. The primary outcome was ACS diagnosed during the primary admission, and the secondary outcome was death or re-infarction within 30-days of initial presentation. Our sample included 750 patients (aged 59 ± 17 years, 42% female), of whom 115 (15.3%) had ACS and 33 (4.4%) had 30-day death or re-infarction. The c-statistics of HEART, TIMI, GRACE, FRISC, and PURSUIT for identifying ACS were 0.87, 0.86, 0.73, 0.84, and 0.79, respectively, and for predicting 30-day death or re-infarction were 0.70, 0.73, 0.72, 0.72, and 0.62, respectively. Sensitivity/negative predictive value of HEART ≥ 4 and TIMI ≥ 3 for ACS detection were 0.94/0.98 and 0.87/0.97, respectively.
CONCLUSIONS
In chest pain patients admitted through EMS, HEART and TIMI outperform other scores for identifying chest pain due to ACS. Although both have similar negative predictive value, HEART has better sensitivity and lower rate of false negative results, thus it can be used preferentially over TIMI in the initial triage of this population.
Identifiants
pubmed: 29907395
pii: S0735-6757(18)30482-0
doi: 10.1016/j.ajem.2018.06.020
pmc: PMC6286698
mid: NIHMS976070
pii:
doi:
Types de publication
Comparative Study
Journal Article
Research Support, N.I.H., Extramural
Langues
eng
Sous-ensembles de citation
IM
Pagination
461-467Subventions
Organisme : NHLBI NIH HHS
ID : R01 HL137761
Pays : United States
Informations de copyright
Copyright © 2018 Elsevier Inc. All rights reserved.
Références
J Electrocardiol. 2015 Nov-Dec;48(6):921-6
pubmed: 26346296
Acad Emerg Med. 2015 Aug;22(8):955-64
pubmed: 26205260
Ann Emerg Med. 2006 Dec;48(6):666-77, 677.e1-9
pubmed: 17014928
Int J Cardiol. 2013 Oct 3;168(3):2153-8
pubmed: 23465250
Circulation. 2000 Jun 6;101(22):2557-67
pubmed: 10840005
JAMA. 2000 Aug 16;284(7):835-42
pubmed: 10938172
Arch Intern Med. 2003 Oct 27;163(19):2345-53
pubmed: 14581255
J Am Coll Cardiol. 2001 Dec;38(7):2114-30
pubmed: 11738323
Med Biol Eng Comput. 2018 Jan;56(1):1-12
pubmed: 28626854
Eur Heart J. 2007 Oct;28(20):2525-38
pubmed: 17951287
Biometrics. 1988 Sep;44(3):837-45
pubmed: 3203132
J Am Heart Assoc. 2015 Jul 24;4(7):
pubmed: 26209692
Acad Emerg Med. 2011 Oct;18(10):1036-44
pubmed: 21996068
Heart Lung. 2014 Nov-Dec;43(6):516-26
pubmed: 24988910
JAMA. 2011 Oct 26;306(16):1794-5
pubmed: 22028355
Clin Chem Lab Med. 2003 Jan;41(1):68-73
pubmed: 12636052
Curr Cardiol Rev. 2011 Feb;7(1):2-8
pubmed: 22294968
Am J Emerg Med. 2014 Jun;32(6):601-5
pubmed: 24731933
J Electrocardiol. 2017 Nov - Dec;50(6):717-724
pubmed: 28916174
Catheter Cardiovasc Interv. 2009 Dec 1;74(7):E25-68
pubmed: 19924773
Crit Pathw Cardiol. 2016 Mar;15(1):1-5
pubmed: 26881812
Int J Cardiol. 2016 Oct 15;221:759-64
pubmed: 27428317
Circulation. 2002 Dec 10;106(24):3018-23
pubmed: 12473545
Neth Heart J. 2008 Jun;16(6):191-6
pubmed: 18665203
Heart. 2005 Aug;91(8):1047-52
pubmed: 16020594
Int J Cardiol. 2017 Jan 15;227:656-661
pubmed: 27810290