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A simple clinical scoring model to predict significant left main/three-vessel disease in non-ST elevation acute
Rayan Jo Rachwan1, Omar Chehab2, Rody G Bou Chaaya3
1Division of Cardiovascular Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States of America.
Insights
The MADISON score identifies high-risk patients with left main and/or three-vessel disease (LM/3VD) in non-ST elevation acute coronary syndrome (NSTE-ACS). A high score reliably flags patients needing urgent care, aiding triage in limited resource settings.
Area of Science:
- Cardiology
- Clinical Prediction Models
- Acute Coronary Syndromes
Background:
- Patients with non-ST elevation acute coronary syndrome (NSTE-ACS) and significant left main and/or three-vessel disease (LM/3VD) face poor outcomes.
- Timely identification and revascularization are crucial but challenged by healthcare resource limitations.
- Effective patient triage is essential to avoid care delays.
Purpose of the Study:
- To identify clinical predictors of LM/3VD at initial NSTE-ACS presentation.
- To develop and validate a predictive model for LM/3VD in NSTE-ACS patients.
- To assess the model's utility in patient triage and prioritization.
Main Methods:
- Retrospective analysis of NSTE-ACS patients from National Cardiovascular Data Registries.
- Logistic regression used to identify predictors and develop the MADISON score in an index cohort.
- Model performance validated in two independent cohorts.
Main Results:
- 24% of 1706 NSTE-ACS patients had LM/3VD.
- The MADISON score incorporates seven predictors: age ≥65, male sex, diabetes, ECG abnormalities, heart rate >90 bpm, stroke/TIA history, and heart failure signs.
- The model achieved an AUC-ROC of 0.67, with high specificity (83.5-95%) but low-to-moderate sensitivity (3.5-34.4%) for LM/3VD at a score ≥4.
Conclusions:
- A MADISON score ≥4 reliably identifies NSTE-ACS patients at increased risk of LM/3VD.
- The score demonstrates high specificity, supporting its use for triage.
- The MADISON score can aid in prioritizing care for high-risk patients in resource-limited settings.
Background:
Patients with non-ST elevation acute coronary syndrome (NSTE-ACS) who have significant left main and/or three-vessel disease (LM/3VD) are at particularly high risk for poor outcomes. Timely identification and revascularization of these patients is essential. However, growing healthcare resource limitations necessitate patient triage and prioritization to avoid delays in care.
Aims:
To identify clinical predictors of LM/3VD available at initial NSTE-ACS presentation and validate a prediction model in independent cohorts.
Methods:
Retrospective data of NSTE-ACS patients from National Cardiovascular Data Registries of three institutional cohorts were analyzed. Logistic regression identified predictors of LM/3VD in an index cohort to develop a predictive model. The model's performance was subsequently evaluated in the remaining two cohorts.
Results:
Among 1706 NSTE-ACS patients, 24 % had LM/3VD. Seven clinical predictors-age ≥ 65, male sex, diabetes, ECG abnormalities, heart rate > 90 bpm, history of stroke/TIA, and signs of heart failure-were used to derive the MADISON score. The model demonstrated an AUC-ROC of 0.67 across cohorts. At the prespecified clinical threshold (score ≥ 4), the MADISON score showed high specificity (83.5-95 %) but low-to-moderate sensitivity (3.5-34.4 %) for LM/3VD detection.
Conclusions:
A high MADISON score (≥4) reliably identifies patients at increased risk of LM/3VD with high specificity, supporting its potential use for triage and prioritization of patient care in resource-limited settings.
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