Early risk assessment in patients with suspected NSTE-ACS; a retrospective cohort study
Kim R R Smulders1, Jesse P A Demandt1, Pieter J Vlaar1
1Department of Cardiology, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands.
Insights
The pre-HEART score effectively identifies low-risk patients with chest pain, ruling out non-ST elevation Acute Coronary Syndrome (NSTE-ACS). This new score, along with the HEART score, shows promise in reducing emergency healthcare burdens.
Area of Science:
- Emergency Medicine
- Cardiology
- Clinical Triage
Background:
- Chest pain is a frequent reason for Emergency Department (ED) visits, with most patients being low risk for Acute Coronary Syndrome (ACS).
- Managing these patients strains healthcare resources, necessitating efficient risk stratification tools.
- Existing risk scores for chest pain triage have varying performance, with a need to identify the best performing scores for ruling out non-ST elevation ACS (NSTE-ACS).
Purpose of the Study:
- To compare the diagnostic accuracy of various risk scores in identifying patients with chest pain who are at low risk for NSTE-ACS.
- To determine the best performing risk score for ruling out NSTE-ACS in the ED setting.
- To evaluate the proportion of low-risk patients identified by different scores at specific safety levels.
Main Methods:
- A retrospective study included 536 adult patients presenting to the ED with suspected NSTE-ACS between January 1, 2019, and July 1, 2019.
- The primary endpoint was confirmed NSTE-ACS during ED presentation or hospitalization, based on 2020 ESC guidelines.
- Secondary analysis assessed the number of low-risk patients identified at 95% and 98% safety levels.
Main Results:
- Of 536 patients, 134 (25.0%) were diagnosed with NSTE-ACS.
- The pre-HEART score (AUC 0.869) and T-MACS score (AUC 0.862) demonstrated the highest diagnostic performance, closely followed by the HEART score (AUC 0.850).
- At a 98% safety level, the HEART score identified 28.9% of patients as low risk while missing zero NSTE-ACS cases; the pre-HEART score identified 18.3% as low risk, also missing zero NSTE-ACS cases.
Conclusions:
- The novel pre-HEART score exhibits practical utility and accurate diagnostic capabilities for NSTE-ACS risk stratification.
- The HEART and T-MACS scores also demonstrated strong performance in this patient cohort.
- Pre-hospital risk scores hold significant promise for improving chest pain triage and alleviating emergency healthcare system burden.
Introduction:
Chest pain is among the most common reasons for Emergency Department (ED) presentation, while most patients should be considered low risk for Acute Coronary Syndrome (ACS). Management of these patients places a significant burden on our health care system. Various risk scores have been developed to facilitate the triage of patients with chest pain. However, it remains unclear which score performs best in identifying low risk patients, in various settings. The aim of this study was to determine which risk score performs best in ruling out non-ST elevation ACS (NSTE-ACS).
Methods:
Data was collected from all patients >18 years presenting to the ED between 01 and 01-2019 and 01-07-2019, if they were suspected of NSTE-ACS. Primary endpoint was NSTE-ACS during presentation to the ED or hospitalization, according to the 2020 ESC guidelines. In a secondary analysis we determined the number low-risk patients, at set safety levels of 95% and 98%.
Results:
A total of 536 patients were included, 192 (35.9%) were admitted to the hospital and NSTE-ACS occurred in 134 of 536 patients (25.0%). When areas under the curve (AUC) were compared, pre-HEART (0.869; CI 0.835-0.903), T-MACS (0.862; CI 0.825-0.898) and HEART (0.850; CI 0.815-0.885) performed best. At a safety level of 98%, the HEART score was the best performing risk score and identified 28.9% of patients as low risk, and missed 0 cases of NSTE-ACS. Followed by the pre-HEART score, which identified 18.3% of all patients as low risk, and missed 0% of NSTE-ACS.
Conclusions:
The newly developed pre-HEART score is both practical and has accurate diagnostic properties, closely followed by the HEART score, and T-MACS. New pre-hospital risk scores are promising and much needed. Future studies should focus on the usage of pre-hospital scores for triage of patients with chest pain, in order to reduce the burden on emergency health care.
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