Risk Stratification for Patients with Chest Pain Discharged Home from the Emergency Department

Abstract

For patients with chest pain who are deemed clinically to be low risk and discharged home from the emergency department (ED), it is unclear whether further laboratory tests can improve risk stratification. Here, we investigated the utility of a clinical chemistry score (CCS), which comprises plasma glucose, the estimated glomerular filtration rate, and high-sensitivity cardiac troponin (I or T) to generate a common score for risk stratification. In a cohort of 14,676 chest pain patients in the province of Ontario, Canada and who were discharged home from the ED (November 2012–February 2013 and April 2013–September 2015) we evaluated the CCS as a risk stratification tool for all-cause mortality, plus hospitalization for myocardial infarction or unstable angina (primary outcome) at 30, 90, and 365 days post-discharge using Cox proportional hazard models. At 30 days the primary outcome occurred in 0.3% of patients with a CCS < 2 (n = 6404), 0.9% of patients with a CCS = 2 (n = 4336), and 2.3% of patients with a CCS > 2 (n = 3936) (p < 0.001). At 90 days, patients with CCS < 2 (median age = 52y (IQR = 46–60), 59.4% female) had an adjusted HR = 0.51 (95% confidence interval (CI) = 0.32–0.82) for the composite outcome and patients with a CCS > 2 (median age = 74y (IQR = 64–82), 48.0% female) had an adjusted HR = 2.80 (95%CI = 1.98–3.97). At 365 days, 1.3%, 3.4%, and 11.1% of patients with a CCS < 2, 2, or >2 respectively, had the composite outcome (p < 0.001). In conclusion, the CCS can risk stratify chest pain patients discharged home from the ED and identifies both low- and high-risk patients who may warrant different medical care.

Acute Phase Response and Non-Reproducible Elevated Concentrations with a High-Sensitivity Cardiac Troponin I Assay

“…Previous estimates of myocardial injury in patients with ACS symptoms are similar between Abbott hs-cTnI (19.7%) and Ortho hs-cTnI (20.8%) [ 18 ] with data presented here further suggesting 1%–2% false positives with Ortho hs-cTnI when re-measured with Roche hs-cTnT. Here, additional variables and tools besides hs-cTn can help mitigate errors in testing to further prevent misclassification in this setting [ 24 , 25 , 26 ]. It is also evident that both sex and age are important variables when assessing myocardial injury, with sex-specific URL cutoffs being recommended for hs-cTn assays [ 1 , 2 , 27 , 28 ].…”

Diagnostic Performance of Serial High-Sensitivity Cardiac Troponin Measurements in the Emergency Setting

“…In two different ED cohorts, we measured hsTnI for research purposes from the same blood samples used concurrently for testing with the non-hsTn assay that was used for clinical purposes. Both cohorts were observational studies and have been previously described using the presentation sample (i.e., the test results from the first sample measurement) [12,13,17,18]. The current retrospective analyses were confined to those participants with two hsTnI results to assess the algorithms (see Figure 1 Cohort-2 was another observational cohort study (NCT01994577) conducted from May 2013 to August 2013 in patients presenting with symptoms suggestive of ACS to the ED at the same three Hamilton hospitals.…”

Admission High-Sensitivity Cardiac Troponin vs a Biochemical Score for Predicting Mortality in Patients With COVID-19

“…1,2 Further improvements in risk-stratification for emergency department or hospitalized patients may be achieved by adding clinical chemistry tests, such as glucose and creatinine (ie, estimated glomerular filtration rate), to generate a clinical chemistry score (CCS). 2,3 For patients with COVID-19, additional biochemical tests may have important prognostic rolesdfor example, urea level, which is already a component of the CURB-65 score (confusion, urea, respiratory rate, blood pressure, age 65 years) used to risk stratify patients presenting to the hospital with pneumonia. 4 We performed a retrospective chart review of COVID-19 patients admitted to hospitals in the city of Hamilton in order to explore the performance characteristics of hs-cTn levels, the CCS, and the CCS with urea (CCUS) to predict in-hospital death.…”

“…2 The CCUS includes the CCS with an additional point of 1 assigned if the urea level was > 7 mmol/L (0 if below), thus yielding a range of 0-6 points. [2][3][4] As 2 different hs-cTnI assays (Abbott ¼ 29 patients; Ortho ¼ 10 patients) were used, we divided the results by the respective upper reference limits to normalize for analyses. Receiver operating characteristic curve analyses with the areas under the curve, and sensitivity and specificity estimates for in-hospital death, were performed.…”