![]() The HEART score outperformed the GRACE and TIMI scores in discriminating between those with and without MACE in chest pain patients, and identified the largest group of low-risk patients at the same level of safety.Īcute coronary syndrome Chest pain Clinical prediction rule GRACE score HEART score TIMI score.Ĭopyright © 2016 The Authors. The TIMI score identified no "low risk" patients at this safety level. At an absolute level of safety of at least 98% sensitivity, the GRACE score identified 231 patients as "low risk" in which 2.2% a MACE was missed the HEART score identified 381 patients as "low risk" with 0.8% missed MACE. Additionally, the number of low-risk patients identified by each score were compared at a fixed level of safety of at least 95% or 98% sensitivity. Performance of the scores was compared by calculating AUC curves. The GRACE and TIMI score were calculated based on prospectively collected data. The HEART score was determined by the treating physician at the ED. The primary outcome was MACE within 6weeks. Similarly, patients with obvious noncardiac causes for their chest pain, such as pulmonary embolism or pneumonia, do not require emergency risk stratification for coronary disease.The performance of the GRACE, HEART and TIMI scores were compared in predicting the probability of major adverse cardiac events (MACE) in chest pain patients presenting at the emergency department (ED), in particular their ability to identify patients at low risk.Ĭhest pain patients presenting at the ED in nine Dutch hospitals were included. Patients with clearly abnormal troponin concentrations require further investigation and do not require an ED chest pain score to guide clinical decision making. Decisions around the need for functional or anatomic cardiac testing after ED discharge are relevant only to patients who have an MI ruled out after troponin testing, hence our focus on this patient population. Therefore, our systematic review summarises the evidence for the performance of these scores in patients in whom structured risk scores to aid decision making around noninvasive testing after ED discharge are most relevant. In contrast, most of the body of related literature evaluates the performance of these scores in undifferentiated chest pain patients (ie, before ruling in or ruling out MI or alternative diagnoses), included MI on the index presentation among the measured outcomes, and used older-generation troponin assays. This systematic review only included studies performed in populations of patients who have had MI ruled out by means of hs-cTn assays, and evaluated the prognostic performance for events occurring after MI has been ruled out. ![]() In accordance with the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies, eligible study designs included prediction model development studies without external validation, prediction score model development studies with external validation, and external score validation studies (with or without model updating). Both quantitative risk prediction models and categoric clinical decision rules were eligible for inclusion in the review, provided that all the variables included in the prediction tool would have been available to the treating physician at the time of the ED assessment. Studies were included if they 1) included adult patients (≥ 18 years old) presenting to the ED with a primary complaint of chest pain or symptoms suggestive of ACS, 2) quantified risk score performance in a population of patients who had MI ruled out at the index visit by means of hs-cTn assays, and 3) assessed the prognostic performance of at least 1 risk prediction score applied in the ED for 30-day MACE (not including events on the index ED visit).
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