Biomarkers After Risk Stratification in Acute Chest Pain (from the BRIC Study)

• Published in: The American journal of cardiology 2013-02, Vol.111 (4), p.493-498
• Main Authors: Mathewkutty, Shiny, MD, Sethi, Sanjum S., MD, Aneja, Ashish, MD, Shah, Kshitij, MD, Iyengar, Rupa L., MPH, Hermann, Luke, MD, Khakimov, Sayyar, BA, Razzouk, Louai, MD, Esquitin, Ricardo, MD, Vedanthan, Rajesh, MD, MPH, Benjamin, Terrie-Ann, MD, MHS, Grace, Marie, PhD, Nisenbaum, Rosane, PhD, Ramanathan, Krishnan, MD, Ramanathan, Lakshmi, PhD, Chesebro, James, MD, Farkouh, Michael E., MD, MSc
• Format: Article
• Language: English
• Subjects: Acute coronary syndromes; Acute Pain - blood; Acute Pain - diagnosis; Acute Pain - etiology; Angina pectoris; Biomarkers; Biomarkers - blood; Cardiovascular; Cardiovascular disease; Chest Pain - blood; Chest Pain - diagnosis; Chest Pain - etiology; Classification; Cystatin C - blood; Diagnosis, Differential; Emergency Service, Hospital; Female; Follow-Up Studies; Health care policy; Heart attacks; Humans; Immunoassay; Incidence; Long term health care; Male; Medical imaging; Middle Aged; Mortality; Myocardial Infarction - diagnosis; Myocardial Infarction - epidemiology; Myocardial Infarction - etiology; Natriuretic Peptide, Brain - blood; Peptide Fragments - blood; Prognosis; Protein Precursors; Retrospective Studies; Risk Assessment - methods; Risk Factors; Triage; United States - epidemiology
• ISSN: 0002-9149; 1879-1913
• DOI: 10.1016/j.amjcard.2012.10.032

Current models incompletely risk-stratify patients with acute chest pain. In this study, N-terminal pro–B-type natriuretic peptide and cystatin C were incorporated into a contemporary chest pain triage algorithm in a clinically stratified population to improve acute coronary syndrome discrimination. Adult patients with chest pain presenting without myocardial infarction (n = 382) were prospectively enrolled from 2008 to 2009. After clinical risk stratification, N-terminal pro–B-type natriuretic peptide and cystatin C were measured and standard care was performed. The primary end point was the result of a clinical stress test. The secondary end point was any major adverse cardiac event at 6 months. Associations were determined through multivariate stratified analyses. In the low-risk group, 76 of 78 patients with normal levels of the 2 biomarkers had normal stress test results (negative predictive value 97%). Normal biomarkers predicted normal stress test results with an odds ratio of 10.56 (p = 0.006). In contrast, 26 of 33 intermediate-risk patients with normal levels of the 2 biomarkers had normal stress test results (negative predictive value 79%). Biomarkers and stress test results were not associated in the intermediate-risk group (odds ratio 2.48, p = 0.09). There were 42 major adverse cardiac events in the overall cohort. No major adverse cardiac events occurred at 6 months in the low-risk subgroup that underwent stress testing. In conclusion, N-terminal pro–B-type natriuretic peptide and cystatin C levels predict the results of stress tests in low-risk patients with chest pain but should not be substituted for stress testing in intermediate-risk patients. There is potential for their use in the early discharge of low-risk patients after clinical risk stratification.