Performance of Coronary Risk Scores Among Patients With Chest Pain in the Emergency Department

Kaiser Permanente CREST Network Investigators

Research output: Contribution to journalArticle

7 Citations (Scopus)

Abstract

Background: Both the modified History, Electrocardiogram, Age, Risk factors and Troponin (HEART) score and the Emergency Department Assessment of Chest pain Score (EDACS) can identify patients with possible acute coronary syndrome (ACS) at low risk (<1%) for major adverse cardiac events (MACE). Objectives: The authors sought to assess the comparative accuracy of the EDACS (original and simplified) and modified HEART risk scores when using cardiac troponin I (cTnI) cutoffs below the 99th percentile, and obtain precise MACE risk estimates. Methods: The authors conducted a retrospective study of adult emergency department (ED) patients evaluated for possible ACS in an integrated health care system between 2013 and 2015. Negative predictive values 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. Results: A total of 118,822 patients with possible ACS were included. The 3 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 negative predictive values (range 99.49% to 99.55%; p = 0.27). The original EDACS identified the largest proportion of patients as low risk (60.6%; p < 0.0001). Conclusions: Among ED patients with possible ACS, the modified HEART score, original EDACS, and simplified EDACS all predicted a low risk of 60-day MACE with improved accuracy using a cTnI cutoff below the 99th percentile. The original EDACS identified the most low-risk patients, and thus may be the preferred risk score.

Original languageEnglish (US)
Pages (from-to)606-616
Number of pages11
JournalJournal of the American College of Cardiology
Volume71
Issue number6
DOIs
StatePublished - Feb 13 2018

Fingerprint

Chest Pain
Hospital Emergency Service
Troponin I
Acute Coronary Syndrome
Troponin
Age Factors
Electrocardiography
History
Integrated Delivery of Health Care
Cardiogenic Shock
Heart Arrest
Retrospective Studies
Myocardial Infarction
Mortality

Keywords

  • acute coronary syndrome
  • myocardial ischemia
  • risk stratification

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Performance of Coronary Risk Scores Among Patients With Chest Pain in the Emergency Department. / Kaiser Permanente CREST Network Investigators.

In: Journal of the American College of Cardiology, Vol. 71, No. 6, 13.02.2018, p. 606-616.

Research output: Contribution to journalArticle

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title = "Performance of Coronary Risk Scores Among Patients With Chest Pain in the Emergency Department",
abstract = "Background: Both the modified History, Electrocardiogram, Age, Risk factors and Troponin (HEART) score and the Emergency Department Assessment of Chest pain Score (EDACS) can identify patients with possible acute coronary syndrome (ACS) at low risk (<1{\%}) for major adverse cardiac events (MACE). Objectives: The authors sought to assess the comparative accuracy of the EDACS (original and simplified) and modified HEART risk scores when using cardiac troponin I (cTnI) cutoffs below the 99th percentile, and obtain precise MACE risk estimates. Methods: The authors conducted a retrospective study of adult emergency department (ED) patients evaluated for possible ACS in an integrated health care system between 2013 and 2015. Negative predictive values 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. Results: A total of 118,822 patients with possible ACS were included. The 3 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 negative predictive values (range 99.49{\%} to 99.55{\%}; p = 0.27). The original EDACS identified the largest proportion of patients as low risk (60.6{\%}; p < 0.0001). Conclusions: Among ED patients with possible ACS, the modified HEART score, original EDACS, and simplified EDACS all predicted a low risk of 60-day MACE with improved accuracy using a cTnI cutoff below the 99th percentile. The original EDACS identified the most low-risk patients, and thus may be the preferred risk score.",
keywords = "acute coronary syndrome, myocardial ischemia, risk stratification",
author = "{Kaiser Permanente CREST Network Investigators} and Mark, {Dustin G.} and Jie Huang and Uli Chettipally and Kene, {Mamata V.} and Anderson, {Megan L.} and Hess, {Erik P.} and Ballard, {Dustin W.} and Vinson, {David R.} and Reed, {Mary E.}",
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AU - Kaiser Permanente CREST Network Investigators

AU - Mark, Dustin G.

AU - Huang, Jie

AU - Chettipally, Uli

AU - Kene, Mamata V.

AU - Anderson, Megan L.

AU - Hess, Erik P.

AU - Ballard, Dustin W.

AU - Vinson, David R.

AU - Reed, Mary E.

PY - 2018/2/13

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KW - myocardial ischemia

KW - risk stratification

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