Risk scores prognostic implementation in patients with chest pain and nondiagnostic electrocardiograms

• Published in: The American journal of emergency medicine 2012-11, Vol.30 (9), p.1719-1728
• Main Authors: Conti, Alberto, MD, Poggioni, Claudio, MD, Viviani, Gabriele, MD, Mariannini, Yuri, MD, Luzzi, Margherita, MD, Cerini, Gabriele, MD, Canuti, Erica, MD, Zanobetti, Maurizio, MD, Innocenti, Francesca, MD, Pini, Riccardo, MD
• Format: Article
• Language: English
• Subjects: Analgesics; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Cardiovascular disease; Chest Pain - diagnosis; Chest Pain - physiopathology; Chi-Square Distribution; Cholesterol; Coronary Disease - diagnosis; Coronary Disease - physiopathology; Decision making; Electrocardiography; Emergency; Emergency medical care; Emergency Service, Hospital - statistics & numerical data; Exercise Test - statistics & numerical data; Female; Heart attacks; Humans; Intensive care medicine; Logistic Models; Male; Medical sciences; Middle Aged; Myocardial infarction; Myocardial Infarction - diagnosis; Myocardial Infarction - physiopathology; Myocardial Revascularization - statistics & numerical data; Neuropharmacology; Pain; Pharmacology. Drug treatments; Prognosis; Regression analysis; Risk Assessment - statistics & numerical data; Risk Factors; ROC Curve
• ISSN: 0735-6757; 1532-8171
• DOI: 10.1016/j.ajem.2012.01.028

Abstract 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.