Chest pain presenting to the Emergency Department—to stratify risk with GRACE or TIMI?

Lyon, Richard; Morris, Andrew Conway; Caesar, David Laksamana; Gray, Sarah M.; Gray, Alasdair

doi:10.1016/j.resuscitation.2006.11.023

Cited by 94 publications

(69 citation statements)

References 4 publications

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“…Although most patients are at low risk, many centres attempt to maximize diagnostic sensitivity by applying comprehensive ruleout protocols involving prolonged monitoring, serial cardiac investigations, provocative or invasive testing, and often admission to observation or coronary care units [6][7][8] ; a recent study from Minnesota reported that nearly all chest pain patients were admitted to hospital. 9 Prediction rules have been developed for ACS risk stratification, 9-16 but few [14][15][16] have been validated and none widely accepted. The 2007 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, 6 the 2005 AHA guidelines, 7 and a recent AHA statement 8 do not discuss early discharge of lowrisk patients without additional testing.…”

Section: Ré Sumémentioning

confidence: 99%

“…14 Lyons and colleagues validated the thrombosis in myocardial infarction (TIMI) score in ED patients with a high likelihood of ACS, 15 but this may be difficult to extrapolate to a general ED population. Several studies have attempted to use Global Registry of Acute Coronary Events (GRACE) or TIMI scores to predict ACS, but 3 to 4% of the low-risk patients had a 30-day ACS outcome, 15,16 a risk that may be unacceptable to clinicians. 21 Many rules are hampered by selection bias, a suboptimal methodological design, or low sensitivity.…”

Section: Comparison With Other Studiesmentioning

confidence: 99%

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Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain

Scheuermeyer

Wong

et al. 2014

CJEM

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Objectives: Current guidelines emphasize that emergency department (ED) patients at low risk for potential ischemic chest pain cannot be discharged without extensive investigations or hospitalization to minimize the risk of missing acute coronary syndrome (ACS). We sought to derive and validate a prediction rule that permitted 20 to 30% of ED patients without ACS safely to be discharged within 2 hours without further provocative cardiac testing. Methods: This prospective cohort study enrolled 1,669 chest pain patients in two blocks in 2000-2003 (development cohort) and 2006 (validation cohort). The primary outcome was 30-day ACS diagnosis. A recursive partitioning model incorporated reliable and predictive cardiac risk factors, pain characteristics, electrocardiographic findings, and cardiac biomarker results. Results: In the derivation cohort, 165 of 763 patients (21.6%) had a 30-day ACS diagnosis. The derived prediction rule was 100.0% sensitive and 18.6% specific. In the validation cohort, 119 of 906 patients (13.1%) had ACS, and the prediction rule was 99.2% sensitive (95% CI 95.4-100.0) and 23.4% specific (95% CI 20.6-26.5). Patients have a very low ACS risk if arrival and 2-hour troponin levels are normal, the initial electrocardiogram is nonischemic, there is no history of ACS or nitrate use, age is , 50 years, and defined pain characteristics are met. The validation of the rule was limited by the lack of consistency in data capture, incomplete follow-up, and lack of evaluation of the accuracy, comfort, and clinical sensibility of this clinical decision rule. Conclusion: The Vancouver Chest Pain Rule may identify a cohort of ED chest pain patients who can be safely discharged within 2 hours without provocative cardiac testing. Further validation across other centres with consistent application and comprehensive and uniform follow-up of all eligible and enrolled patients, in addition to measuring and reporting the accuracy of and comfort level with applying the rule and the clinical sensibility, should be completed prior to adoption and implementation. RÉ SUMÉObjectif: D'aprè s les lignes directrices actuelles, on ne peut renvoyer du service des urgences (SU) les patients qui souffrent de douleurs thoraciques de nature probablement isché mique mais qui connaissent un faible risque de maladie cardiaque sans d'abord leur faire subir une exploration approfondie ou sans les hospitaliser afin de ré duire le plus possible le risque de syndrome coronarien aigu (SCA) passé inaperç u. Aussi avons-nous tenté d'é laborer et de valider une rè gle pré visionnelle qui permettrait de renvoyer en toute sé curité de 20 à 30% des patients ne souffrant pas d'un SCA au cours des 2 heures suivant leur arrivé e au SU, et ce, sans leur faire subir d'autres é preuves d'exploration cardiaque. August 20, 2012) suggest over 600,000 annual ED visits. Between 2 and 5% of patients with acute coronary syndrome (ACS) may be discharged with an incorrect non-ACS diagnosis and no further follow-up, 3,4 leading to adverse patient ...

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Section: Ré Sumémentioning

confidence: 99%

Section: Comparison With Other Studiesmentioning

confidence: 99%

Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain

Scheuermeyer

Wong

et al. 2014

CJEM

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“…[16][17][18][19][20][21][22][23] Three studies were conducted in the United States, two in the United Kingdom, two in Spain, two in Italy and one in Canada. The mean age ranged from 53.6 to 71.3 years.…”

Section: Characteristics Of the Included Studiesmentioning

confidence: 99%

“…One study reported a sensitivity of 100% and a specificity of 13%, with data needed to calculate a complete GRACE score missing for 24% of patients. 22 The focused nature of the research question, however, enabled careful assessment and meta-analysis of studies with limited clinical heterogeneity.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

Diagnostic accuracy of the TIMI risk score in patients with chest pain in the emergency department: a meta-analysis

Hess

Agarwal

Chandra

et al. 2010

Canadian Medical Association Journal

113

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C hest pain is a common presenting complaint in the emergency department that requires efficient risk stratification, timely initiation of treatment in highrisk patients and safe determination of patient disposition. Several studies have been published that stratify the risk of patients in the emergency department with chest pain. [1][2][3][4][5] However, only the Thrombolysis in Myocardial Infarction (TIMI) risk score, which was initially developed for use in patients with unstable angina or non-ST-segment elevation myocardial infarction or both, 6 has been broadly validated in several independent emergency department populations with chest pain and thus constitutes the highest level of evidence available. The TIMI risk score assigns each of seven predictors a value of one point, allowing stratification of patients into one of eight prognostic categories (Box 1). 6 The clinical end points are acute myocardial infarction, coronary revascularization and death from any cause.A robust estimate of the performance of the TIMI risk score obtained from a systematic review may prove useful to both clinicians and researchers. Clinicians would have a reliable quantitative estimate of a patient's short-term risk of a cardiac event. This could be used as an adjunct to clinical acumen and as a tool to communicate risk to patients in a shared decision-making model of care.7 Researchers would also have an estimate of the prognostic accuracy of the TIMI risk score derived from different practice settings and patient populations that represent a wide variety of ethnic backgrounds. This estimate may serve as a useful baseline for comparison as emerging clinical prediction rules and imaging modalities continue to refine our approach to diagnosis and risk stratification in patients in the emergency department with potential acute coronary syndromes.We conducted a comprehensive systematic review and meta-analysis to assess the methodological quality and prognostic performance of studies that had prospectively validated the TIMI risk score in patients in the emergency department. MethodsThis systematic review and meta-analysis adheres to the reporting guidelines of Meta-analysis of Observational Studies in Epidemiology (MOOSE) 8 and the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) statement as applicable to meta-analyses of observational studies. Background: The Thrombolysis in Myocardial Infarction (TIMI) risk score uses clinical data to predict the short-term risk of acute myocardial infarction, coronary revascularization or death from any cause. It was originally developed for use in patients with unstable angina or non-STelevation myocardial infarction. We sought to expand the clinical application of the TIMI risk score by assessing its prognostic accuracy in patients in the emergency department with potential acute coronary syndromes.

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“…En otros escenarios clínicos, la mayor facilidad de uso del Score TIMI puede ser una ventaja. Por ejemplo, Lyon et al 16 demostró exactitud similar entre los dos scores en pacientes con dolor torácico en el sector de emergencia, situación en que fue fácil obtener informaciones para el Score TIMI, comparado al GRACE 16 .…”

Section: óBito Infarto No Fatal O Angina Refractariaunclassified

Valor prognóstico do Escore de Risco GRACE versus Escore de Risco TIMI em síndromes coronarianas agudas

Correia¹,

Freitas²,

Bittencourt³

et al. 2010

Arq. Bras. Cardiol.

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Artículo recibido el 16/05/09; revisado recibido el 14/10/09; aceptado el 30/10/09. ResumenFundamento: Aunque el Score de Riesgo TIMI sea el más utilizado en síndromes coronarios agudos sin supradesnivel del segmento ST (SCA), el Score GRACE tiene potencial superioridad pronóstica, pues fue creado a partir de un registro observacional, parte de las variables son tratadas de forma semicuantitativa y la función renal se computa en su cálculo.Objetivo: Probar la hipótesis de que el Score de Riesgo GRACE tiene superior valor pronóstico hospitalario, comparado con el Score TIMI en pacientes ingresados con SCA. el GRACE se creó a partir de un registro observacional, la edad se computa en varios niveles, la función renal y señales de disfunción ventricular izquierda componen parte de este Score. Por lo tanto, resulta importante comprar el valor predictivo de estos dos scores, a fin de determinar si la mayor complejidad del GRACE está compensada por una superioridad pronóstica clínicamente relevante. MétodosDe esta forma, el objetivo del presente estudio es probar la hipótesis de que el Score GRACE posee superior capacidad pronóstica con relación al Score TIMI, referente a eventos derivados durante la fase hospitalaria de pacientes con SCA. Esta hipótesis se probó en una muestra de pacientes ingresados consecutivamente con angina inestable o infarto agudo de miocardio sin supradesnivel del segmento ST, comparando el desempeño de estos dos scores con relación a los desenlaces de fallecimiento, infarto no fatal y angina refractaria durante la hospitalización. Métodos Selección de la PoblaciónFueron considerados candidatos al estudio, individuos ingresados consecutivamente en la Unidad Coronaria de IntroducciónPacientes con síndromes coronarios agudos sin supradesnivel del ST (SCA) poseen un amplio espectro de gravedad, la cual varía de acuerdo con características clínicas y de laboratorio 1 . De esta forma, para la toma de decisiones clínicas resulta esencial una efectiva estratificación de riesgo. Está demostrado que la utilización de modelos multivariados en la forma de scores representa el medio más preciso para la predicción de riesgo, superior al obtenido subjetivamente por la impresión clínica 2 .El Score de Riesgo TIMI fue el primer modelo validado, provenientes del estudio de cohortes de ensayos clínicos intervencionistas 3 . Este Score fue rápidamente difundido en la práctica clínica, teniendo a su favor la simplicidad de aplicación. El Score GRACE es de validación más reciente y posee aplicación más compleja, pues considera un mayor número de variables, algunas de ellas tratadas de forma semicuantitativa 4 . Por otro lado, algunas características favorecen su capacidad predictiva: 595

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Chest pain presenting to the Emergency Department—to stratify risk with GRACE or TIMI?

Cited by 94 publications

References 4 publications

Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain

Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain

Diagnostic accuracy of the TIMI risk score in patients with chest pain in the emergency department: a meta-analysis

Valor prognóstico do Escore de Risco GRACE versus Escore de Risco TIMI em síndromes coronarianas agudas

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