A practical approach with outcome for the prognostic assessment of non-ST-segment elevation chest pain and normal
Juan Sanchis1, Vicent Bodí, Julio Núñez
1Servei de Cardiologia, Hospital Clínic Universitari, Universitat de València, Barcelona, Spain. sanchis_juafor@gva.es
Insights
A validated risk score effectively stratifies patients with non-ST-elevation chest pain. Low-risk patients (Group 1) have significantly better outcomes than higher-risk groups, including those with ST depression or troponin increase.
Area of Science:
- Cardiology
- Emergency Medicine
Background:
- Non-ST-elevation chest pain patients are a diverse group.
- Risk stratification is crucial for managing these patients.
Purpose of the Study:
- To compare outcomes of chest pain patients with normal troponin, categorized by a risk score, against those with ST depression or troponin increase.
- To evaluate the utility of a validated risk score in stratifying patients with non-ST-elevation chest pain.
Main Methods:
- 1,449 patients with non-ST-elevation chest pain were analyzed.
- A risk score based on pain characteristics and risk factors was applied to patients without ST depression or troponin increase, defining four risk groups.
- Outcomes (death or myocardial infarction) were assessed over a median 26-month follow-up.
Main Results:
- Low-risk patients (Group 1: risk score <3) had significantly fewer 30-day (1.7%) and long-term (9.4%) events compared to higher-risk groups (Groups 2, 3, and 4).
- Groups 2 (risk score ≥3, no ST depression/troponin), 3 (ST depression, no troponin), and 4 (troponin increase) showed similar, poorer outcomes.
- Multivariate analysis confirmed risk group as a predictor of 30-day and long-term outcomes.
Conclusions:
- A validated risk score can identify a high-risk subgroup among patients with normal troponin and no ST deviation.
- This high-risk subgroup has a prognosis similar to patients with ST depression or troponin increase.
- The risk score provides a practical classification for the spectrum of non-ST-elevation chest pain.
Abstract:
Patients with non-ST-elevation chest pain constitute a heterogeneous population. Our aim is to compare the outcome of patients with chest pain, non-ST-segment deviation, and normal troponin, categorized using a risk score, with that of patients with ST depression or troponin increase. A total of 1,449 patients with non-ST-elevation chest pain were evaluated. A validated risk score (using pain characteristics and risk factors) was applied to patients without ST depression or troponin increase. Accordingly, 4 risk categories were defined: group 1, no troponin increase, no ST depression, and risk score <3 points (n = 633); group 2, no troponin increase, no ST depression, but risk score > or = 3 points (n = 158); group 3, no troponin increase, ST depression (n = 106); and group 4, troponin increase (n = 552). Median follow-up was 26 months, and the end point was death or myocardial infarction. Group 1 experienced fewer events at 30 days (1.7%, p = 0.0001) and long-term follow-up (9.4%, p = 0.0001) than groups 2 (10.8% and 26%), 3 (6.6% and 30%), and 4 (9.5% and 25%). Kaplan-Meier curves overlapped among groups 2, 3, and 4, whereas group 1 showed a flatter curve (p = 0.0001). Using multivariate analysis, risk group (group 1 vs remaining groups) predicted 30-day (p = 0.0003) and long-term (p = 0.0001) outcome. There were no differences among groups 2, 3, and 4. In conclusion, application of a risk score to patients without troponin increase or ST deviation identified a high-risk group with prognosis similar to that of patients with troponin increase or ST depression and affords a practical classification for the full spectrum of non-ST-elevation chest pain.
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