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Risk scores prognostic implementation in patients with chest pain and nondiagnostic electrocardiograms
Alberto Conti1, Claudio Poggioni, Gabriele Viviani
1Emergency Medicine, Department of Critical Care Medicine and Surgery, University of Florence and Careggi University Hospital, 50134 Florence, Italy. aaaconti@hotmail.com
Insights
The Florence Prediction Rule (FPR) effectively identifies low-risk patients with chest pain who will not experience coronary events. Exercise ECG may be less reliable for these patients, despite being an independent predictor.
Area of Science:
- Cardiology
- Emergency Medicine
- Diagnostic Accuracy
Background:
- Chest pain evaluation relies on various prognostic risk scores.
- Accurate risk stratification is crucial for effective patient management in emergency settings.
Purpose of the Study:
- To compare the predictive performance of six risk scores (Grace, Pursuit, TIMI, Goldman, Sanchis, FPR) against exercise ECG.
- To evaluate their effectiveness in decision-making and patient outcomes for chest pain presentations.
Main Methods:
- Patients with nondiagnostic ECGs, normal troponins, and no prior coronary disease history underwent exercise ECG.
- Positive exercise ECG led to coronary angiography; negative results led to discharge.
- The primary endpoint included coronary stenosis, cardiovascular death, myocardial infarction, angina, or revascularization within 12 months.
Main Results:
- The Florence Prediction Rule (FPR) demonstrated the highest predictive accuracy (AUC=0.74), outperforming Goldman and Grace scores.
- FPR effectively identified low-risk patients unlikely to experience adverse events.
- Exercise ECG was an independent predictor of coronary events (P < .001).
Conclusions:
- The Florence Prediction Rule (FPR) is effective in ruling out coronary events in low-risk chest pain patients.
- The utility of exercise ECG in this low-risk subset warrants further consideration.
Background:
Several risk scores are available for prognostic purpose in patients presenting with chest pain.
Aim:
The aim of this study was to compare Grace, Pursuit, Thrombolysis in Myocardial Infarction (TIMI), Goldman, Sanchis, and Florence Prediction Rule (FPR) to exercise electrocardiogram (ECG), decision making, and outcome in the emergency setting.
Methods:
Patients with nondiagnostic ECGs and normal troponins and without history of coronary disease underwent exercise ECG. Patients with positive testing underwent coronary angiography; otherwise, they were discharged. End point was the composite of coronary stenosis at angiography or cardiovascular death, myocardial infarction, angina, and revascularization at 12-month follow-up.
Results:
Of 508 patients considered, 320 had no history of coronary disease: 29 were unable to perform exercise testing, and finally, 291 were enrolled. Areas under the receiver operating characteristic curves for Grace, Pursuit, TIMI, Goldman, Sanchis, and FPR were 0.59, 0.68, 0.69, 0.543, 0.66, and 0.74, respectively (P < .05 FPR vs Goldman and Grace). In patients with negative exercise ECG and overall low risk score, only the FPR effectively succeeded in recognizing those who achieved the end point; in patients with high risk score, the additional presence of carotid stenosis and recurrent angina predicted the end point (odds ratio, 12 and 5, respectively). Overall, logistic regression analysis including exercise ECG, coronary risk factors, and risk scores showed that exercise ECG was an independent predictor of coronary events (P < .001).
Conclusions:
The FPR effectively succeeds in ruling out coronary events in patients categorized with overall low risk score. Exercise ECG, nonetheless being an independent predictor of coronary events could be considered questionable in this subset of patients.
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