When is low-risk chest pain acceptable risk chest pain?

Brace-McDonnell, Samantha J.; Laing, Simon

doi:10.1136/heartjnl-2014-306177

Cited by 5 publications

(6 citation statements)

References 7 publications

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“…Although H-FABP was a strong predictor of ACS in our original study, its inclusion may present a barrier to clinical implementation at some centres, which has been highlighted in the literature 12 13. This new evidence suggests that a model using hs-cTnT as the only biomarker gives comparable sensitivity and greater specificity as a ‘rule out’ tool.…”

Section: Discussionmentioning

confidence: 64%

Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid: single biomarker re-derivation and external validation in three cohorts

et al. 2016

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BackgroundThe original Manchester Acute Coronary Syndromes model (MACS) ‘rules in’ and ‘rules out’ acute coronary syndromes (ACS) using high sensitivity cardiac troponin T (hs-cTnT) and heart-type fatty acid binding protein (H-FABP) measured at admission. The latter is not always available. We aimed to refine and validate MACS as Troponin-only Manchester Acute Coronary Syndromes (T-MACS), cutting down the biomarkers to just hs-cTnT.MethodsWe present secondary analyses from four prospective diagnostic cohort studies including patients presenting to the ED with suspected ACS. Data were collected and hs-cTnT measured on arrival. The primary outcome was ACS, defined as prevalent acute myocardial infarction (AMI) or incident death, AMI or coronary revascularisation within 30 days. T-MACS was built in one cohort (derivation set) and validated in three external cohorts (validation set).ResultsAt the ‘rule out’ threshold, in the derivation set (n=703), T-MACS had 99.3% (95% CI 97.3% to 99.9%) negative predictive value (NPV) and 98.7% (95.3%–99.8%) sensitivity for ACS, ‘ruling out’ 37.7% patients (specificity 47.6%, positive predictive value (PPV) 34.0%). In the validation set (n=1459), T-MACS had 99.3% (98.3%–99.8%) NPV and 98.1% (95.2%–99.5%) sensitivity, ‘ruling out’ 40.4% (n=590) patients (specificity 47.0%, PPV 23.9%). T-MACS would ‘rule in’ 10.1% and 4.7% patients in the respective sets, of which 100.0% and 91.3% had ACS. C-statistics for the original and refined rules were similar (T-MACS 0.91 vs MACS 0.90 on validation).ConclusionsT-MACS could ‘rule out’ ACS in 40% of patients, while ‘ruling in’ 5% at highest risk using a single hs-cTnT measurement on arrival. As a clinical decision aid, T-MACS could therefore help to conserve healthcare resources.

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Section: Discussionmentioning

confidence: 64%

Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid: single biomarker re-derivation and external validation in three cohorts

et al. 2016

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“…It is to be debated what is an acceptable yet achievable missed event rate for patients with chest pain in our current healthcare system with ED overcrowding. 5 …”

Section: Discussionmentioning

confidence: 99%

“… 4 The question remains whether this conservative approach leads to better clinical outcomes for patients and there is discussion on optimal management in patients who are deemed safe to discharge from the ED. 5 …”

Section: Introductionmentioning

confidence: 99%

Medical consumption compared for TIMI and HEART score in chest pain patients at the emergency department: a retrospective cost analysis

et al. 2016

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ObjectiveTo investigate which risk score (TIMI score or HEART score) identifies the largest population of low-risk patients at the emergency department (ED). Furthermore, we retrospectively calculated the corresponding expected decrease in medical consumption if these patients would have been discharged from the ED.MethodsWe performed analyses in two hospitals of the multicentre prospective validation study of the HEART score, executed in 2008 and 2009. Patients with chest pain presenting to the ED were included and information was collected on major adverse cardiac events (MACEs) and on hospital admissions and diagnostic procedures within 6 weeks. The TIMI and HEART score were calculated for each patient.ResultsWe analysed 640 patients (59% male, mean age of 60, cumulative incidence of MACE 17%). An estimated total of €763 468 was spent during follow-up on hospital admission and diagnostic procedures. In total, 256 (40%) patients had a HEART score of 0–3 and were considered low risk (miss rate 1.6%), a total of €64 107 was spent on diagnostic procedures and hospital admission after initial presentation in this group. In comparison, 105 (16%) patients with TIMI score of 0 were considered low risk (miss rate 0%), with a total of €14 670 spent on diagnostic procedures and initial hospital admission costs. With different cut-offs for low risk, HEART 0–2 (miss rate 0.7%), would have resulted in a total of €25 365 in savings, compared with €71 905 when an alternative low risk cut-off for TIMI of TIMI≤1 would be used (miss rate 3.0%).ConclusionsThe HEART score identifies more patients as low risk compared with the TIMI score, which may lead to a larger reduction in diagnostic procedures and costs in this low-risk group. Future studies should prospectively investigate whether adhering to the HEART score in clinical practice and early discharge of low-risk patients is safe and leads to a reduction in medical consumption.

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“…Studies documenting MACE frequency15–18 have varied with respect to the type of populations studied, the durations of follow-up, and their clinical settings (eg, ED rather than RACPC). As such, the definition of an ‘acceptable’ MACE rate is still a subject of debate 19. While a 2% risk of MACE may seem low, if extrapolated to the 700 000 annual ED admissions for chest pain, potentially translates into 14 000 patients every year experiencing a major cardiac event within the first 6 months from presentation and up to 70 000 subsequently being diagnosed with significant CAD, having previously been denied further investigation at the time of presentation.…”

Section: Discussionmentioning

confidence: 99%

Clinical outcomes when applying NICE guidance for the investigation of recent-onset chest pain to a rapid-access chest pain clinic population

Patterson

Nair

Ahmed

et al. 2014

Heart

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When is low-risk chest pain acceptable risk chest pain?

Cited by 5 publications

References 7 publications

Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid: single biomarker re-derivation and external validation in three cohorts

Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid: single biomarker re-derivation and external validation in three cohorts

Medical consumption compared for TIMI and HEART score in chest pain patients at the emergency department: a retrospective cost analysis

Clinical outcomes when applying NICE guidance for the investigation of recent-onset chest pain to a rapid-access chest pain clinic population

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