A new simple risk score in patients with acute chest pain without existing known coronary disease

Abstract

Objective: To derive and validate a prediction rule in patients with acute chest pain (CP) without existing known coronary disease. Methods: Cohort study including 2233 patients with CP. Based on clinical judgment, 1435 were discharged as very low risk and the remaining 798 underwent exercise tolerance test (ETT). End point: 6-month composite of cardiovascular death, nonfatal myocardial infarction, and revascularization. The prediction rule was derived from a randomly selected test cohort (n = 1106) summing factors of variables selected by multivariate regression analysis: CP score higher than 6 (factor of 3), male gender, age older than 50 years, metabolic syndrome, and diabetes mellitus (factor of 1, for each). The prediction rule was validated in the remaining cohort (n = 1127). All patients with CP were categorized into 3 groups: group A (prediction rule 0-1), B (2-4), or C (5-6). Outcomes and prognostic yield of ETT were compared among each group. Results: In the test cohort, 55 patients (5%) reached the composite end point. Event rate increased as the prediction rule increased: 1% for group A, 6% for B, and 25% for C (P b .001). This pattern was confirmed in the validation cohort (P b .001). A normal ETT did not significantly improve the high (99%) negative predictive value in group A and did not succeed in excluding the composite end point (17%) in group C. Conclusions: In patients with acute CP without existing coronary disease, a prediction rule based on clinical characteristics provided a useful method for prognostication with possible implication in decision making.

Risk scores prognostic implementation in patients with chest pain and nondiagnostic electrocardiograms

“…The present study analyzed the impact of clinical application of all the available risk scores as Grace, Pursuit, TIMI, Goldman, Sanchis, and the FPR [6][7][8][9][10][11][12][13] in a cohort of 291 patients with CP with negative first-line workup and without known coronary disease. These patients were usually labeled as low-risk patients, and they eventually showed coronary events up to 20% [3,5,17,21].…”

“…Enrolled patients with CP were categorized by all the previously validated risk scores (Grace, Pursuit, TIMI, Goldman, Sanchis, and FPR) [6][7][8][9][10][11][12][13]. Patients were characterized also by the presence of coronary risk factors such as diabetes, metabolic syndrome, hypertension, high blood cholesterol, familial history of coronary disease, and current smoking.…”

“…The novel FPR is a simple score strictly based on few clinical characteristics on presentation: CP score greater than 6, male sex, age 50 years or older, diabetes, or metabolic syndrome (Tables 1 and 2) [6][7][8][9][10][11][12][13].…”

“…To date, submitting patients to stress testing is usually based on nonstandardized clinical judgment [3,5]. Afterwards, several prediction rules are available for risk stratification in patients with CP; however, some of these have been tested in high-risk patients [6][7][8][9][10], whereas others, in low-risk patients [11][12][13]. In addition, some prediction rules are based on clinical data, whereas others used only major risk factors for atherosclerosis [14][15][16].…”

“…The objective of this study was to characterize a cohort of patients with CP presenting to the ED with risk scores calculated by Grace, Pursuit, TIMI, Goldman, Sanchis, and Florence Prediction Rules (FPRs) [6][7][8][9][11][12][13] and compare the scores to outcomes.…”