Dataset Information

Performance of risk scores for coronary artery disease: a retrospective cohort study of patients with chest pain in urgent primary care.

ABSTRACT:

Objective

To evaluate the diagnostic performance of the Marburg Heart Score (MHS), INTERCHEST, Gencer rule, Bruins Slot rule and compare these with unaided clinical judgement in patients with chest pain in urgent primary care.

Design

Retrospective, cohort study.

Setting

Regional primary care facility responsible for out-of-hours primary care for a quarter-million people in the Netherlands.

Participants

Consecutive patients aged ≥18 years who were evaluated for chest pain.

Main outcome measures

Discriminatory ability (C-statistic), sensitivity, specificity, positive and negative predictive values (PPV/NPV). The reference standard involved a composite endpoint of the occurrence of death, acute coronary syndrome or coronary revascularisation (=major adverse cardiac events; MACE) up to 6 weeks after initial contact.

Results

A total of 664 patients were included, of whom 4.8% (n=32) had a MACE event. C-statistics for MHS, INTERCHEST, Gencer and Bruins Slot rule were: 0.77 (95% CI 0.69 to 0.84), 0.85 (95% CI 0.78 to 0.92), 0.72 (95% CI 0.63 to 0.81) and 0.72 (95% CI 0.63 to 0.81), respectively. Optimal diagnostic accuracy was found for MHS ≥2 (sensitivity=81.3%, specificity=67.1%, PPV=11.1%, NPV=98.6%), INTERCHEST ≥2 (sensitivity=87.5%, specificity=78.8%, PPV=17.3%, NPV=99.1%), Gencer ≥2 (sensitivity=84.4%, specificity=37.8%, PPV=6.4%, NPV=98.0%) and Bruins Slot≥2 (sensitivity=90.6%, specificity=40.8%, PPV=7.2%, NPV=98.9%). Physicians referred 157 patients (23.6%) and missed 6 out of 32 MACEs (sensitivity=81.3%, specificity=79.3%, PPV=16.6%, NPV=98.8%). Using INTERCHEST with a referral threshold of ≥2 points, 4 MACEs would have been missed and 162 patients (24.4%) referred. The other risk scores resulted in far higher referral rates.

Conclusion

While available risk scores have reasonable to good discriminatory properties, they do not outperform unaided clinical judgment for evaluating chest pain in urgent primary care. Only the INTERCHEST score may slightly improve risk stratification.

SUBMITTER: Kleton M

PROVIDER: S-EPMC8655518 | biostudies-literature | 2021 Dec

REPOSITORIES: biostudies-literature

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Publications

Performance of risk scores for coronary artery disease: a retrospective cohort study of patients with chest pain in urgent primary care.

Kleton Michelle M Manten Amy A Smits Iris I Rietveld Remco R Lucassen Wim A M WAM Harskamp Ralf E RE

BMJ open 20211208 12

<h4>Objective</h4>To evaluate the diagnostic performance of the Marburg Heart Score (MHS), INTERCHEST, Gencer rule, Bruins Slot rule and compare these with unaided clinical judgement in patients with chest pain in urgent primary care.<h4>Design</h4>Retrospective, cohort study.<h4>Setting</h4>Regional primary care facility responsible for out-of-hours primary care for a quarter-million people in the Netherlands.<h4>Participants</h4>Consecutive patients aged ≥18 years who were evaluated for chest ...[more]

PMID: 34880006

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Project description:Background: Chest pain is a prevalent and critical complaint among patients in emergency departments (EDs) across the United States. Professional societies have refined clinical guidelines to establish the most effective diagnostic pathways for identifying obstructive coronary artery disease. However, many healthcare systems do not adhere to the guideline-validated clinical pathways and instead order repeat diagnostic testing. This study evaluated the efficiency of care delivered to chest pain patients in our tertiary medical center. Methods: We performed a retrospective chart review of patients presenting to our ED with acute chest pain between November and December 2022, collecting information about chest pain, the testing received, and their outcomes. The data were then reviewed to determine clinical practice patterns. Results: We included 342 patients, with a mean age of 54 years; 54.7% of study participants were females. Patients who were eventually admitted from the ED (46.5%, n = 159) were either under observation or inpatient status. Furthermore, 16.6%, n = 57, of patients had an ischemic evaluation within the preceding year. Physicians documented a HEART score in 24.6%, n = 84 of the patients. While HEART score is a considerable factor utilized by admitting physicians to triage incoming patients, 39%, n = 62, of all admitted patients had a low HEART score (<3) and a negative ischemic evaluation within the past year. Conclusions: This single-center retrospective analysis of care delivery for non-ACS (acute coronary syndrome) chest pain patients demonstrated that the HEART score was not thoroughly documented in the study population. This resulted in an overperformance of inpatient ischemic testing, with an increased length of stay and costs for the institution and healthcare system. This study serves as a quality improvement initiative to explore similar data within their institutions and as a reminder of the importance of utilizing validated clinical pathways to streamline clinical care and reduce healthcare costs.

Project description:ObjectiveChest pain scores allow emergency department (ED) physicians to identify low-risk patients for whom discharge can be safely expedited. Although these have been extensively validated in Western cohorts, data in patients of Asian heritage are lacking. This study aimed to determine the accuracy of HEART, ED Assessment of Chest Pain Score (EDACS), and Global Registry of Acute Coronary Events (GRACE) in risk-stratifying which chest pain patients are at risk of major adverse cardiovascular events within 30 days (composite of all-cause mortality, acute myocardial infarction and coronary revascularization).MethodsThis single-center prospective cohort-study that enrolled 1200 patients was conducted by a large urban tertiary center in Singapore. Chest pain scores were reported before disposition by research assistants blinded to the physician's clinical assessment. Outcomes were assessed independently by a blinded cardiologist and emergency physician, while another cardiologist adjudicated in the case of discrepancies.ResultsOf the 1195 patients analyzed, 135 (11.3%) suffered major adverse cardiovascular events within 30 days. HEART, which ruled out major adverse cardiovascular events in 52.8% of patients with 88.1% sensitivity, and EDACS, which ruled out major adverse cardiovascular events in 57.5% of patients with 83.7% sensitivity, proved comparable to clinical judgment that ruled out major adverse cardiovascular events in 73.0% of patients with 85.5% sensitivity. GRACE was weaker-ruling out major adverse cardiovascular events in 79.2% of patients with a dismal sensitivity of 45.0%. The correlation-statistic for HEART (79.4%) was superior to EDACS (69.9%) and GRACE (69.2%).ConclusionsHEART more accurately identified low-risk chest pain patients in an Asian ED, demonstrating comparable performance characteristics to clinical judgment. This has major implications on the use of chest pain scores to safely expedite disposition decisions for low-risk chest pain patients.

Dataset Information

Performance of risk scores for coronary artery disease: a retrospective cohort study of patients with chest pain in urgent primary care.

Objective

Design

Setting

Participants

Main outcome measures

Results

Conclusion

Publications

Performance of risk scores for coronary artery disease: a retrospective cohort study of patients with chest pain in urgent primary care.

Similar Datasets

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