Clinical risk scores identify more patients at risk for cardiovascular events within 30 days as compared to standard ACS risk criteria: the WESTCOR study

Abstract

Aims Troponin-based algorithms are made to identify myocardial infarctions (MIs) but adding either standard acute coronary syndrome (ACS) risk criteria or a clinical risk score may identify more patients eligible for early discharge and patients in need of urgent revascularization. Methods and results Post-hoc analysis of the WESTCOR study including 932 patients (mean 63 years, 61% male) with suspected NSTE-ACS. Serum samples were collected at 0, 3, and 8–12 h and high-sensitivity cTnT (Roche Diagnostics) and cTnI (Abbott Diagnostics) were analysed. The primary endpoint was MI, all-cause mortality, and unplanned revascularizations within 30 days. Secondary endpoint was non-ST-elevation myocardial infarction (NSTEMI) during index hospitalization. Two combinations were compared: troponin-based algorithms (ESC 0/3 h and the High-STEACS algorithm) and either ACS risk criteria recommended in the ESC guidelines, or one of eleven clinical risk scores, HEART, mHEART, CARE, GRACE, T-MACS, sT-MACS, TIMI, EDACS, sEDACS, Goldman, and Geleijnse–Sanchis. The prevalence of primary events was 21%. Patients ruled out for NSTEMI and regarded low risk of ACS according to ESC guidelines had 3.8–4.9% risk of an event, primarily unplanned revascularizations. Using HEART score instead of ACS risk criteria reduced the number of events to 2.2–2.7%, with maintained efficacy. The secondary endpoint was met by 13%. The troponin-based algorithms without evaluation of ACS risk missed three-index NSTEMIs with a negative predictive value (NPV) of 99.5% and 99.6%. Conclusion Combining ESC 0/3 h or the High-STEACS algorithm with standardized clinical risk scores instead of ACS risk criteria halved the prevalence of rule-out patients in need of revascularization, with maintained efficacy.

The performance of HEAR score for identification of low-risk chest pain: a systematic review and meta-analysis

“…We tried to communicate with the corresponding authors of the abstracts via email for their published studies in full text, but received only studies that were already included. Therefore, 10 studies were finally included and considered eligible for systematic review and analysis [9,10,33–40] (Supplementary Figure 1, Supplemental digital content 2, http://links.lww.com/EJEM/A332 ).…”

“…In this systematic review, 33 843 patients were included from 10 studies [9,10,33–40]. Five studies were conducted in Europe [9,33,34,38,40], one in Asia [37], and the rest in North America [10,35,36,39]. Seven studies were conducted in the EDs [9,10,34–38] and three studies were in the prehospital [33,39,40].…”

“…We tried to communicate with the corresponding authors of the abstracts via email for their published studies in full text, but received only studies that were already included. Therefore, 10 studies were finally included and considered eligible for systematic review and analysis [9,10,33-40] (Supplementary Figure 1, In this systematic review, 33 843 patients were included from 10 studies [9,10,[33][34][35][36][37][38][39][40]. Five studies were conducted in Europe [9,33,34,38,40], one in Asia [37], and the rest in North America [10,35,36,39].…”

“…Five studies were conducted in Europe [9,33,34,38,40], one in Asia [37], and the rest in North America [10,35,36,39]. Seven studies were conducted in the EDs [9,10,[34][35][36][37][38] and three studies were in the prehospital [33,39,40]. Seven studies considered patients with the HEAR score below 2 [9,10,[33][34][35][36]38] and three studies marked scores below 4 as low risk [37,39,40].…”

Advanced cardiovascular risk prediction in the emergency department: updating a clinical prediction model – a large database study protocol

“…T-MACS has been externally validated in 1,459 patients from three prospective studies in the United Kingdom [5], 1,244 patients from Australasia [6], and multicentre prospective trials from the United Kingdom [7], Thailand [8] and Norway [9], each of which demonstrated acceptable predictive performance. A pilot randomized controlled trial of a precursor version of the algorithm showed that its use led to significantly more safe discharges from the ED within 4 hours of arrival than standard care [10].…”