Each score was retrospectively applied to each patient in our study. 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. 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). In this study, we compared the performance of nine risks scores within the same population of patients presenting with undifferentiated chest pain to the ED of a tertiary hospital in whom clear-cut noncardiac diagnoses were absent. 8 Studies comparing performance of different scores in the same population are few, 9 – 13 and, to our knowledge, none have compared more than three scores within one patient population. Systematic reviews comparing different scores rely on data from reports that usually focus on a single score. 7 Differences between studies that assess single scores relating to definitions of clinical variables, ECG changes, and tests, patient populations, and reference outcomes render assessment of relative performance difficult. Scores derived from high-risk populations with probable or definite myocardial infarction (MI) or ACS at ED presentation have limited generalizability to undifferentiated patients at lower risk. To date, more than 12 risk stratification scores for chest pain exist, 6 but which performs best in predicting risk of CHD among patients in whom clear-cut noncardiac diagnoses have been excluded remains unclear. 1 Tools are needed that accurately identify patients at intermediate to high risk of CHD requiring further in-patient evaluation, and those at low risk who can be quickly and safely discharged. 4Īccordingly, guidelines recommend risk stratification and investigations for ruling out ACS, but these can incur lengthy ED stays, in-patient admissions, and downstream testing with low diagnostic yield, 5 all at substantial cost. Estimates of ACS risk based on risk factors, clinical findings, initial electrocardiographs (ECGs), and clinical judgment are insufficiently sensitive to exclude ACS 2, 3 with the level of confidence most ED physicians desire. 1 While more than 80% of cases do not have acute coronary syndrome (ACS), 1 missing this diagnosis has major morbidity and mortality implications. In Australia 500,000 patients present with chest pain to emergency departments (EDs) annually, comprising 5%–10% of ED presentations. These results have practical implications for clinicians involved in caring for patients presenting to ED with undifferentiated chest pain. The remaining five scores demonstrated intermediate performance. They found that, in distinguishing low-risk patients from high-risk patients, the North American Chest Pain Rule performed best followed closely by the History, ECG, Age, Risk Factors, and Troponin score and Thrombolysis in Myocardial Infarction score, with the Accelerated Diagnostic Protocol to Assess Patients with Chest Pain Symptoms Using Contemporary Troponins score performing worst. Dr Wamala’s team for the first time compared the performance of nine different risk scores within the same population of patients presenting with undifferentiated chest pain to the ED of a tertiary hospital. To date, more than 12 risk stratification scores for undifferentiated chest pain exist, but which performs best in predicting risk of CHD remains unclear. Tools are needed that accurately identify patients at intermediate to high risk of CHD who warrant further in-patient evaluation, and those at low risk who can be quickly and safely discharged. Risk factors, clinical findings, initial electrocardiographs (ECGs), and clinical judgment are insufficiently sensitive to exclude acute myocardial ischemia with the level of confidence most clinicians desire. After excluding the small percentage with clear-cut evidence of myocardial infarction or other acute noncardiac pathologies on presentation, identifying the 10%–20% of remaining patients with undifferentiated chest pain who have ischemic chest pain due to coronary heart disease (CHD) constitutes a clinical challenge. Chest pain accounts for 5%–10% of presentations to emergency departments (EDs).
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