Early risk assessment in patients with suspected NSTE-ACS; a retrospective cohort study

• Published in: The American journal of emergency medicine 2022-10, Vol.60, p.106-115
• Main Authors: Smulders, Kim R.R., Demandt, Jesse P.A., Vlaar, Pieter J.
• Format: Article
• Language: English
• Subjects: Acute coronary syndromes; Angina pectoris; Chest; Cohort analysis; Diagnostic tests; Emergency medical care; Emergency medical services; EMS; Health care; Health risk assessment; Health risks; Heart; Heart attacks; HEART-score; Medical research; Myocardial infarction; NSTE-ACS; Pain; Paramedics; Patients; Pre-HEART; Pre-hospital; Radiation; Risk assessment; Risk groups; Risk score; Secondary analysis; Triage
• ISSN: 0735-6757; 1532-8171
• DOI: 10.1016/j.ajem.2022.07.053

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). 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%. 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. 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.