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Goldman algorithm. Four groups into which patients can be categorized according to risk of major cardiac events within 72 hours after admission.
Source publication
Background:
Several risk scores are available for prognostic purpose in patients presenting with chest pain.
Aim:
The aim of this study was to compare Grace, Pursuit, Thrombolysis in Myocardial Infarction (TIMI), Goldman, Sanchis, and Florence Prediction Rule (FPR) to exercise electrocardiogram (ECG), decision making, and outcome in the emergenc...
Citations
... However, neither TIMI nor GRACE scores were designed for ED chest pain risk stratification. The relevance of their use for MACE prediction and patient disposition in ED undifferentiated chest pain is up for debate [15][16][17][18]. Boubaker et al. have shown that both scores had low prognostic value and do not serve as an effective risk stratification tool in Tunisian chest pain population [19]. ...
Background
Chest pain remains one of the most challenging serious complaints in the emergency department (ED). A prompt and accurate risk stratification tool for chest pain patients is paramount to help physcian effectively progrnosticate outcomes. HEART score is considered one of the best scores for chest pain risk stratification. However, most validation studies of HEART score were not performed in populations different from those included in the original one.
Objective
To validate HEART score as a prognostication tool, among Tunisian ED patients with undifferentiated chest pain.
Methods
Our prospective, multicenter study enrolled adult patients presenting with chest pain at chest pain units. Patients over 30 years of age with a primary complaint of chest pain were enrolled. HEART score was calculated for every patient. The primary outcome was major cardiovascular events (MACE) occurrence, including all-cause mortality, non-fatal myocardial infarction (MI), and coronary revascularisation over 30 days following the ED visit. The discriminative power of HEART score was evaluated by the area under the ROC curve. A calibration analysis of the HEART score in this population was performed using Hosmer–Lemeshow goodness of test.
Results
We enrolled 3880 patients (age 56.3; 59.5% males). The application of HEART score showed that most patients were in intermediate risk category (55.3%). Within 30 days of ED visit, MACE were reported in 628 (16.2%) patients, with an incidence of 1.2% in the low risk group, 10.8% in the intermediate risk group and 62.4% in the high risk group. The area under receiver operating characteristic curve was 0.87 (95% CI 0.85–0.88). HEART score was not well calibrated (χ 2 statistic = 12.34; p = 0.03).
Conclusion
HEART score showed a good discrimination performance in predicting MACE occurrence at 30 days for Tunisian patients with undifferentiated acute chest pain. Heart score was not well calibrated in our population.
... The nine risk scores, with full acronyms listed in Box 1, comprised History, ECG, Age, Risk Factors, and Troponin (HEART), 14 Accelerated Diagnostic Protocol to Assess Patients with Chest Pain Symptoms Using Contemporary Troponins (ADAPT), 15 Emergency Department Assessment of Chest Pain Score (EDACS), 16 The North American Chest Pain Rule (NACPR), 17 Thrombolysis in Myocardial Infarction (TIMI), 18 modified TIMI (m.TIMI), 19 Global Registry of Acute Coronary Events (GRACE), 20 Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT), 21 and Florence Prediction Rule (FPR). 22 Supplementary material S1 describes each score in detail based on original studies, and we used the cut-points to distinguish low-risk patients from high-risk patients, where either intermediate or high risk in the original studies was classified here as high risk. Each score was retrospectively applied to each patient in our study. ...
Introduction
We compared performance of nine risk scores for coronary heart disease (CHD) among patients presenting to an emergency department (ED) with undifferentiated chest pain of possible coronary origin.
Methods
A retrospective study was undertaken of adult patients presenting with chest pain to atertiary hospital ED with no electrocardiographs or troponin results diagnostic of ischemic chest pain (ICP) or acute coronary syndrome at ED presentation, and no clearly evident noncoronary diagnosis. Risk scores were applied using cut-points distinguishing low- from high-risk patients according to discharge diagnosis of noncardiac chest pain (NCCP) or ICP, respectively. A lower odds ratio (OR) for ICP denoted lower risk for ICP. Score performance was compared using area under receiver–operator characteristic curves (AUC) and predictive values.
Results
A total of 401 patients were studied, of whom 123 (30.7%) had ICP as final diagnosis. Among the nine risk scores, those with greatest ability to detect low-risk patients were The North American Chest Pain Rule (NACPR) score (OR=0.35, 95% CI=0.27–0.46); History, ECG, Age, Risk Factors, and Troponin (HEART) score (OR=0.43; 95% CI=0.35–0.52); and Thrombolysis in Myocardial Infarction (TIMI) score (OR=0.49; 95% CI=0.41–0.58). Discrimination between patients with NCCP and those with ICP was greatest for HEART score (AUC=0.82; 95% CI=0.78–0.86) and lowest for Accelerated Diagnostic Protocol to Assess Patients with Chest Pain Symptoms Using Contemporary Troponins (ADAPT) score (AUC=0.63; 95% CI=0.58–0.69). In excluding ICP, ADAPT had negative predictive value (NPV) 100% (miss rate 0%) but classified only 1.7% of patients as low risk, compared to NACPR with NPV 98% (miss rate 2%), classifying 10.2% as low risk, and HEART with NPV 94% (miss rate 6%), classifying 32.4% as low risk.
Conclusion
The NACPR risk score maximized yield of low-risk patients with lowest miss rate for ICP, while HEART score classified highest proportion of low-risk patients but with a higher miss rate.
... Nuestro estudio se centró en la capacidad diagnóstica de estas escalas, lo cual se convierte en un punto diferenciador frente a los trabajos ya discutidos. En este sentido encontramos dos trabajos que tuvieron un enfoque similar al nuestro, por un lado Fersmire y Cols., evaluaron las escalas HEART y HEARTS3 considerando como desenlace el diagnóstico de infarto intrahospitalario o del síndrome coronario agudo a 30 días 32 , y por otro lado, Conti y Cols., compararon varias escalas incluyendo la presencia de obstrucción coronaria documentada por cateterismo, el diagnóstico de angina o infarto junto con los otros desenlaces cardiovasculares mayores 33 . En ambos casos se encontró una buena capacidad discriminativa, en especial en el primer caso, con un resultado similar al presente reporte. ...
Introducción: El dolor torácico es uno de los principales motivos de consulta en el servicio de urgencias. Diferentes escalas de riesgo han sido evaluadas en los pacientes con dolor torácico. El objetivo del presente estudio es comparar el desempeño diagnóstico de las escalas de riesgo en los pacientes con dolor torácico y sospecha de síndrome coronario agudo.
Métodos: Estudio de pruebas diagnósticas que incluyó pacientes mayores de 18 años con dolor torácico y sospecha de síndrome coronario agudo. El estándar de referencia fue alguna prueba de estratificación coronaria invasiva o no invasiva y la prueba índice la constituyó la puntuación de las escalas de riesgo TIMI, GRACE, CARdiac, Florencia, Sanchis y HEART. Se calcularon las características operativas para diferentes puntos de corte y se compararon las áreas bajo la curva ROC.
Resultados: Se incluyeron 249 pacientes, 143 (57,4%) fueron de sexo masculino, 65,3 años de edad media; 73 (29,3%) fueron anginas inestables, 79 (31,7%) presentaron infartos agudos de miocardio sin elevación del ST y a 97 (39%) se les descartó la enfermedad coronaria. Las escalas HEART y TIMI mostraron el mejor rendimiento diagnóstico con un área bajo la curva de 0,75 (IC del 95% 0,69-0,81) y 0,71 (IC del 95% 0,65-0,77). Las áreas bajo la curva de Florencia, CARdiac, GRACE, y Sanchis fueron 0,64 (IC 95% 0,57-0,71), 0,63 (IC 95% 0,57-0,69), 0,62 (IC 95% 0,55-0,69), y 0,62 (IC 95% 0,55-0,69), respectivamente.
Conclusiones: En una población de pacientes con alta probabilidad para el síndrome coronario agudo, las escalas HEART y TIMI mostraron una mayor capacidad para discriminar el diagnóstico del síndrome coronario agudo.
... Nuestro estudio se centró en la capacidad diagnóstica de estas escalas, lo cual se convierte en un punto diferenciador frente a los trabajos ya discutidos. En este sentido encontramos dos trabajos que tuvieron un enfoque similar al nuestro, por un lado Fersmire y Cols., evaluaron las escalas HEART y HEARTS3 considerando como desenlace el diagnóstico de infarto intrahospitalario o del síndrome coronario agudo a 30 días 32 , y por otro lado, Conti y Cols., compararon varias escalas incluyendo la presencia de obstrucción coronaria documentada por cateterismo, el diagnóstico de angina o infarto junto con los otros desenlaces cardiovasculares mayores 33 . En ambos casos se encontró una buena capacidad discriminativa, en especial en el primer caso, con un resultado similar al presente reporte. ...
Revista Colombiana de Cardiología CARDIOLOGÍA DEL ADULTO-ARTÍCULO ORIGINAL Aplicación de las escalas de estratificación del riesgo en el diagnóstico de los síndromes coronarios agudos Recibido el 11 de agosto de 2016; aceptado el 6 de noviembre de 2016 Disponible en Internet el 5 de enero de 2017 PALABRAS CLAVE Dolor torácico; Síndrome coronario agudo; Infarto de miocardio; Angina; Diagnóstico Resumen Introducción: El dolor torácico es uno de los principales motivos de consulta en el servicio de urgencias. Diferentes escalas de riesgo han sido evaluadas en los pacientes con dolor torácico. El objetivo del presente estudio es comparar el desempeño diagnóstico de las escalas de riesgo en los pacientes con dolor torácico y sospecha de síndrome coronario agudo. Métodos: Estudio de pruebas diagnósticas que incluyó pacientes mayores de 18 años con dolor torácico y sospecha de síndrome coronario agudo. El estándar de referencia fue alguna prueba de estratificación coronaria invasiva o no invasiva y la prueba índice la constituyó la puntuación de las escalas de riesgo TIMI, GRACE, CARdiac, Florencia, Sanchis y HEART. Se calcularon las características operativas para diferentes puntos de corte y se compararon las áreas bajo la curva ROC. Resultados: Se incluyeron 249 pacientes, 143 (57,4%) fueron de sexo masculino, 65,3 años de edad media; 73 (29,3%) fueron anginas inestables, 79 (31,7%) presentaron infartos agudos de miocardio sin elevación del ST y a 97 (39%) se les descartó la enfermedad coronaria. Las escalas HEART y TIMI mostraron el mejor rendimiento diagnóstico con un área bajo la curva de 0,75 (IC del 95% 0,69-0,81) y 0,71 (IC del 95% 0,65-0,77). Las áreas bajo la curva de Florencia, CARdiac, GRACE, y Sanchis fueron 0,64 (IC 95% 0,57-0,71), 0,63 (IC 95% 0,57-0,69), 0,62 (IC 95% 0,55-0,69), y 0,62 (IC 95% 0,55-0,69), respectivamente. Conclusiones: En una población de pacientes con alta probabilidad para el síndrome coronario agudo, las escalas HEART y TIMI mostraron una mayor capacidad para discriminar el diagnóstico del síndrome coronario agudo.
... The Thrombolysis in Myocardial Infarction (TIMI) score 10 with others like history, electrocardiogram, age, risk factors, and troponin (HEART), Global Registry of Acute Coronary Events (GRACE) and Banach scores [11][12][13] are the most used scales to risk stratify patients with chest pain, but it was not validated as a method to determine who has ACS. [14][15][16][17][18] The Geleijnse score reflects the character of the pain and the TIMI score reflects the cardiovascular risk factors, but each score separately does not have a satisfactory performance to eliminate Myocardial Infarction (MI). We hypothesised that combining these two scores could have a better diagnostic performance of ACS than each score considered alone. ...
Acute coronary syndrome (ACS) represents a difficult diagnostic challenge in patients with undifferentiated chest pain. There is a need for a valid clinical score to improve diagnostic accuracy.
To compare the performance of a model combining the Thrombolysis in Myocardial Infarction (TIMI) score and a score describing chest pain (ACS diagnostic score: ACSD score) with that of both scores alone in the diagnosis of ACS in ED patients with chest pain associated with a non-diagnostic ECG and normal troponin.
In this observational cohort study, we enrolled 809 patients admitted to a chest pain unit with normal ECG and normal troponin. They were prospectively evaluated in order to calculate TIMI score, chest pain characteristics score and ACSD score. Diagnosis of ACS was the primary outcome and defined on the basis of 2 cardiologists after reviewing the patient medical records and follow-up data. Mortality and major cardiovascular events were followed for 1 month for patients discharged directly from ED. Discriminative power of scores was evaluated by the area under the ROC curve.
ACS was confirmed in 90 patients (11.1%). The area under the ROC curve for ACSD score was 0.85 (95% CI 0.80 to 0.90) compared with 0.74 (95% CI 0.67 to 0.81) for TIMI and 0.79 (95% CI 0.74 to 0.84) for chest pain characteristics score. A threshold value of 9 appeared to optimise sensitivity (92%) and negative predictive value (99%) without excessively compromising specificity (62%) and positive predictive value (23%).
The ACSD score showed a good discrimination performance and an excellent negative predictive value which allows safely ruling out ACS in ED patients with undifferentiated chest pain. Our findings should be validated in a larger multicentre study.
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We evaluated the ability of a stress-test (Str-T) to improve the risk stratification based on prognostic scores in patients presenting to the ED with chest pain. Between 2008, June and 2013, December, 1082 patients with chest pain were evaluated with an imaging Str-T. With a retrospective analysis, patients were stratified according to: (1) Florence Prediction Rule as low (0–1, LR-FPR), intermediate (2–4, IR-FPR), high risk (5–6, HR-FPR), respectively, 26, 50 and 24% of patients; (2) HEART score as LR-HEART, (0–3) and HR-HEART (≥4), respectively, 36 and 64%; (3) likelihood of CAD according to NICE guidelines, 10–29% LR-NICE, 30–60% IR-NICE and > 60% HR-NICE, respectively, 12, 18 and 70%. Scores’ diagnostic performance was calculated with Str-T as reference. One-month follow-up by a phone call was performed, to investigate the occurrence of new cardiovascular events. In LR and HR patients, FPR and NICE score showed sensitivity 66 vs 93%, specificity 59 vs 19% (both p < 0.001), Positive Predictive Value (PPV) 36 vs 31%, Negative Predictive Value (NPV) 83 vs 87%. Among LR-HEART patients, Str-T was positive for inducible ischemia in 53 (14%) patients and 12 (4%) of them underwent a percutaneous coronary revascularization. The Str-T was negative for inducible ischemia in 760 (70%) patients, positive in 272 (25%), inconclusive in 50 (5%); among patients in the LR and IR subgroups, incidence of CAD (1.3 and 1.6%) and the cumulative incidence of significant events at 1-month follow-up (both 1%) was very low Str-T improved prognostic scores’ diagnostic performance in LR- and HR-subgroups.
Purpose
The Thrombolysis in Myocardial Infarction (TIMI) and the Global Registry in Acute Coronary Events (GRACE) scores were largely evaluated and validated in stratifying risk of cardiovascular events in patients with chest pain and acute coronary syndrome. Our objective was to compare these 2 scores in predicting outcome in emergency department (ED) patients with undifferentiated chest pain.
Materials and methods
This was a prospective cohort study including patients presenting to 4 EDs with chest pain with nondiagnostic or normal ECG. For all included patients (n = 3125), TIMI and GRACE scores were calculated. Follow-up was conducted at 30-day and 1-year post-ED index admission to identify major adverse events. Main outcome included all cause mortality, acute coronary syndrome, and coronary non-ED planned revascularization. Prognostic performance of the scores was assessed by the receiver operating characteristic (ROC) curves.
Results
We reported 285 (9.1%) major adverse events at 30 days and 436 (13.9%) at 1 year. In patients with low TIMI (≤ 2) and GRACE (< 109) scores, a significant proportion had major adverse events at 30 days (5% and 7.5%, respectively) and 1 year (7.9% and 12.9%, respectively). Area under ROC curve at 30 days was 0.66 (95% confidence interval [CI], 0.62-0.71) vs 0.57 (95% CI, 0.53-0.62), respectively, for TIMI and GRACE scores. At 1 year, the area under ROC was 0.67 (95% CI, 0.62-0.71) and 0.65 (95% CI, 0.60-0.70), respectively, for TIMI and GRACE scores.
Conclusions
The TIMI and GRACE scores are not valid in short- and long-term risk stratification in our chest pain patients.
Objectives
To evaluate how often newly developed risk prediction models undergo external validation and how well they perform in such validations.
Study Design and Setting
We reviewed derivation studies of newly proposed risk models and their subsequent external validations. Study characteristics, outcome(s), and models' discriminatory performance [area under the curve, (AUC)] in derivation and validation studies were extracted. We estimated the probability of having a validation, change in discriminatory performance with more stringent external validation by overlapping or different authors compared to the derivation estimates.
Results
We evaluated 127 new prediction models. Of those, for 32 models (25%), at least an external validation study was identified; in 22 models (17%), the validation had been done by entirely different authors. The probability of having an external validation by different authors within 5 years was 16%. AUC estimates significantly decreased during external validation vs. the derivation study [median AUC change: −0.05 (P < 0.001) overall; −0.04 (P = 0.009) for validation by overlapping authors; −0.05 (P < 0.001) for validation by different authors]. On external validation, AUC decreased by at least 0.03 in 19 models and never increased by at least 0.03 (P < 0.001).
Conclusion
External independent validation of predictive models in different studies is uncommon. Predictive performance may worsen substantially on external validation.
Coronary computed tomography angiography (coronary CTA) is a viable alternative to functional imaging in the assessment of patients presenting with acute chest pain (ACP) to the emergency department (ED). The Society of Cardiovascular Computed Tomography Guidelines Committee was formed to develop recommendations for acquiring, interpreting, and reporting of cardiovascular CT to ensure adequate, safe, and efficient use of this modality. Because of the increasing extension of coronary CTA testing for the evaluation of ACP patients, the Committee has been charged with the development of the present document to assist physicians and technologists. These recommendations were produced as an educational tool for practitioners to improve the diagnostic care of patients presenting with acute chest pain to the ED, in the interest of developing systematic standards of practice for coronary CTA based on the best available data or broad expert consensus. Due to the highly variable nature of medical care, and individual and unique patient presentations and circumstances, approaches to patient selection, preparation, protocol selection, interpretation or reporting that differs from these guidelines may represent an appropriate variation based on a legitimate assessment of an individual patient’s needs.
The Society of Cardiovascular Computed Tomography Guidelines Committee makes every effort to avoid any actual or potential conflicts of interest that might arise as a result of an outside relationship or a personal interest of a member of the Guidelines Committee or its Writing Groups. Specifically, all members of the Guidelines Committee and of both Writing Committees are asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest relevant to the document topic. The relationships with industry information for Writing Group and Committee members are available in the Acknowledgments section of this document. These are reviewed by the Guidelines Committee and will be updated as changes occur.
The externality-tangibility (E-T) model of human performance is a human performance technology (HPT) model that categorizes nine all-inclusive elements of HPT into families of elements that can be external or internal to a performer and tangible or intangible. This second of three installments looks at the five factors that are external to a performer and are tangible: tools, environment, incentives, information, and job aids.
