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Risk scores predict 60-day major adverse CV events in possible ACS
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Sixty-day major adverse CV events were accurately predicted by three risk scores when a cardiac troponin I cutoff less than the 99th percentile was used in patients presenting to the ED with possible ACS, according to a study published in the Journal of the American College of Cardiology.
The scores were the original Emergency Department Assessment of Chest Pain Score, or EDACS, simplified EDACS and the modified History ECG, Age, Risk Factors and Troponin, or HEART, score.
Chest pain in ED
In this retrospective study, Dustin G. Mark, MD, senior physician in the department of critical care and emergency medicine at Kaiser Permanente in Oakland, California, and colleagues analyzed data from 118,822 patients (median age, 59 years; 43% men) who went to the ED with either a chief complaint of chest discomfort or chest pain, or had a primary or secondary diagnosis of chest pain by an ED physician between 2013 and 2015. Patients also had cardiac troponin I testing performed during the ED visit. These data were used to calculate original EDACS, simplified EDACS and modified HEART scores.
Exclusion criteria included factors such as a diagnosis of cardiac arrest, MI or cardiogenic shock in the ED or 30 days before the visit and a cardiac troponin I concentration greater than the 99th percentile.
The primary outcome was cumulative 60-day major adverse CV events rate, which was a composite of cardiac arrest, MI, all-cause mortality and cardiogenic shock. The secondary endpoint of interest was major adverse CV events that included surgical or percutaneous coronary revascularization.
Accuracy improvements
Reclassification yields ranged from 3.4% to 3.93% in all three risk scores with a lower cardiac troponin I cutoff of less than 0.02 ng/mL.
The negative predictive values were for the three risk scores were lower for 60-day major adverse CV events and ranged from 99.49% to 99.55% (P = .27). More low-risk patients were identified using the original EDACS (60.6%; 95% CI, 60.3-60.9) compared with the simplified EDACS (48.1%; 95% CI, 47.8-48.3) and the modified HEART scores (51.8%; 95% CI, 51.6-52.1; P < .0001).
“Large prospective studies to confirm the safety of ED discharge with deferral of functional or anatomic cardiac testing among low-risk subgroups are needed,” Mark and colleagues wrote.
“With rising costs and increasing pressure to reduce hospitalizations, a clear tension is present,” James L. Januzzi Jr., MD, cardiologist at Massachusetts General Hospital and professor of medicine at Harvard Medical School, and Cian P. McCarthy, MB, BCh, BAO, clinical fellow in medicine at Massachusetts General Hospital, wrote in a related editorial. “On the one hand, we cannot admit every patient to evaluate chest discomfort, but on the other hand, missing a high-risk cardiac diagnosis is not acceptable. In this modern health care environment, ED physicians are confronted with a most challenging task. With several available clinical risk scores with significant ability to exclude MI while simultaneously identifying substantial numbers of lower-risk patients suitable for early discharge, we may finally have a suitable gatekeeper to assist the pressurized decision making that occurs in the ED setting.” – by Darlene Dobkowski
Disclosures: This study was funded by a Kaiser Permanente Northern California Delivery Science Grant. The authors and McCarthy report no relevant financial disclosures. Januzzi reports he has received grant support from Prevencio, Siemens and Singulex; has received consultant fees from Critical Diagnostics, Novartis, Philips and Roche Diagnostics; and participates in clinical endpoint committees/data safety monitoring boards for Amgen, Boehringer Ingelheim, Janssen and Novartis.
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