Abstract
Background
Accurate risk stratification for obstructive coronary artery disease (CAD) and major
cardiac adverse events (MACE) is important in emergency departments. We compared six
established chest pain risk scores (the HEART score, CAD basic model, CAD clinical
model, TIMI, GRACE, uDF) for prediction of obstructive CAD and MACE.
Methods
Patients who presented to the emergency department with chest pain or symptoms of
suspected CAD and underwent coronary computed tomographic angiography were analyzed.
The primary endpoint was adverse outcomes including the presence of obstructive CAD
(≥50% stenosis) and the occurrence of MACE within 6 weeks. We compared the risk scores
by the area under the receiver-operating characteristic curve (AUC) and calculated
their respective net reclassification index (NRI).
Results
Adverse outcomes occurred in 285 (28.4%) out of the 1002 patients included. For the
prediction of adverse outcomes, the AUC of the HEART score (0.792) was superior to
those of the CAD clinical model (0.760), CAD basic model (0.749), TIMI (0.749), uDF
(0.703), and GRACE (0.653). In terms of the NRI, the HEART score significantly improved
the reclassification abilities of the uDF (0.39), GRACE score (0.27), CAD basic model
(0.11), TIMI (0.10), and CAD clinical model (0.08) (all P < 0.05). The HEART score also had the highest negative predictive value as well (0.893).
Conclusions
The HEART score was superior to other cardiac risk scores in predicting both obstructive
CAD and MACE. However, due to the high false-negative rate (11%) of the HEART score,
its use for identifying low-risk patients should be considered with caution.
Keywords
To read this article in full you will need to make a payment
One-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to The American Journal of Emergency MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Cardiovascular risk and events in 17 low-, middle-, and high-income countries.N Engl J Med. 2014; 371: 818-827https://doi.org/10.1056/NEJMoa1311890
- Low diagnostic yield of elective coronary angiography.N Engl J Med. 2010; 362: 886-895https://doi.org/10.1056/NEJMoa0907272
- 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.Circulation. 2012; 126: e354-e471https://doi.org/10.1161/CIR.0b013e318277d6a0
- 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology.Eur Heart J. 2013; 34: 2949-3003https://doi.org/10.1093/eurheartj/eht296
- Application of the TIMI risk score for unstable angina and non-ST elevation acute coronary syndrome to an unselected emergency department chest pain population.Acad Emerg Med. 2006; 13: 13-18https://doi.org/10.1197/j.aem.2005.06.031
- The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making.JAMA. 2000; 284: 835-842https://doi.org/10.1001/jama.284.7.835
- Chest pain in the emergency room: a multicenter validation of the HEART Score.Crit Pathw Cardiol. 2010; 9: 164-169https://doi.org/10.1097/HPC.0b013e3181ec36d8
- Relation between the GRACE score and severity of atherosclerosis in acute coronary syndrome.J Cardiol. 2014; 63: 24-28https://doi.org/10.1016/j.jjcc.2013.06.017
- Accuracy of the TIMI and GRACE scores in predicting coronary disease in patients with non-ST-elevation acute coronary syndrome.Rev Port Cardiol. 2018; 37: 41-49https://doi.org/10.1016/j.repc.2017.05.012
- Correlation of TIMI risk score with angiographic severity and extent of coronary artery disease in patients with non-ST-elevation acute coronary syndromes.Am J Cardiol. 2004; 93: 813-816https://doi.org/10.1016/j.amjcard.2003.12.015
- The prognostic significance of 50% coronary stenosis in medically treated patients with coronary artery disease.Circulation. 1980; 62: 240-248https://doi.org/10.1161/01.cir.62.2.240
- Effect of using the HEART score in patients with chest pain in the emergency department: a stepped-wedge, cluster randomized trial.Ann Intern Med. 2017; 166: 689-697https://doi.org/10.7326/M16-1600
- Third universal definition of myocardial infarction.Circulation. 2012; 126: 2020-2035https://doi.org/10.1161/CIR.0b013e31826e1058
- Use of the Centaur TnI-Ultra assay for detection of myocardial infarction and adverse events in patients presenting with symptoms suggestive of acute coronary syndrome.Clin Chem. 2008; 54: 723-728https://doi.org/10.1373/clinchem.2007.097162
- Pre-test probability of obstructive coronary stenosis in patients undergoing coronary CT angiography: comparative performance of the modified diamond-Forrester algorithm versus methods incorporating cardiovascular risk factors.Int J Cardiol. 2016; 222: 346-351https://doi.org/10.1016/j.ijcard.2016.07.180
- Diagnostic value of the updated Diamond and Forrester score to predict coronary artery disease in patients with acute-onset chest pain.Cardiology. 2016; 133: 10-17https://doi.org/10.1159/000438980
- Prediction model to estimate presence of coronary artery disease: retrospective pooled analysis of existing cohorts.BMJ. 2012; 344: e3485https://doi.org/10.1136/bmj.e3485
- Do GRACE (Global Registry of Acute Coronary events) risk scores still maintain their performance for predicting mortality in the era of contemporary management of acute coronary syndromes.Am Heart J. 2010; 160 (e1-3): 826-834
- Chest pain in the emergency room: value of the HEART score.Neth Heart J. 2008; 16: 191-196https://doi.org/10.1007/bf03086144
- ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC).Eur Heart J. 2011; 32: 2999-3054https://doi.org/10.1093/eurheartj/ehr236
- Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach.Biometrics. 1988; 44: 837-845
- Net reclassification indices for evaluating risk prediction instruments: a critical review.Epidemiology. 2014; 25: 114-121https://doi.org/10.1097/ede.0000000000000018
- Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond.Stat Med. 2008; 27 (discussion 207-12): 157-172
- Comparison of the GRACE, HEART and TIMI score to predict major adverse cardiac events in chest pain patients at the emergency department.Int J Cardiol. 2017; 227: 656-661https://doi.org/10.1016/j.ijcard.2016.10.080
- Comparing HEART, TIMI, and GRACE scores for prediction of 30-day major adverse cardiac events in high acuity chest pain patients in the emergency department.Int J Cardiol. 2016; 221: 759-764https://doi.org/10.1016/j.ijcard.2016.07.147
- Contemporary emergency department management of patients with chest pain: a concise review and guide for the high-sensitivity troponin era.Can J Cardiol. 2018; 34: 98-108https://doi.org/10.1016/j.cjca.2017.11.012
- High-sensitivity troponin assays for the early rule-out or diagnosis of acute myocardial infarction in people with acute chest pain: a systematic review and cost-effectiveness analysis.Health Technol Assess. 2015; 19: 1-234https://doi.org/10.3310/hta19440
- European Society of Cardiology-recommended coronary artery disease consortium pretest probability scores more accurately predict obstructive coronary disease and cardiovascular events than the Diamond and Forrester score: the Partners Registry.Circulation. 2016; 134: 201-211https://doi.org/10.1161/CIRCULATIONAHA.116.023396
- A clinical prediction rule for the diagnosis of coronary artery disease: validation, updating, and extension.Eur Heart J. 2011; 32: 1316-1330https://doi.org/10.1093/eurheartj/ehr014
- Risk stratifying chest pain patients in the emergency department using HEART, GRACE and TIMI scores, with a single contemporary troponin result, to predict major adverse cardiac events.Emerg Med J. 2018; 35: 420-427https://doi.org/10.1136/emermed-2017-207172
- Development and validation of the emergency department assessment of chest pain score and 2 h accelerated diagnostic protocol.Emerg Med Australas. 2014; 26: 34-44https://doi.org/10.1111/1742-6723.12164
- Performance of coronary risk scores among patients with chest pain in the emergency department.J Am Coll Cardiol. 2018; 71: 606-616https://doi.org/10.1016/j.jacc.2017.11.064
- Risk stratification of patients suspected of coronary artery disease: comparison of five different models.Atherosclerosis. 2012; 220: 557-562https://doi.org/10.1016/j.atherosclerosis.2011.11.027
- Comparison of the Diamond-Forrester method and Duke Clinical Score to predict obstructive coronary artery disease by computed tomographic angiography.Am J Cardiol. 2012; 109: 998-1004https://doi.org/10.1016/j.amjcard.2011.11.028
Article Info
Publication History
Published online: June 10, 2020
Accepted:
June 4,
2020
Received in revised form:
May 31,
2020
Received:
February 20,
2020
Identification
Copyright
© 2020 Elsevier Inc. All rights reserved.
