Comparison of nine coronary risk scores in evaluating patients presenting to hospital with undifferentiated chest pain
Received 11 August 2018
Accepted for publication 5 November 2018
Published 13 December 2018 Volume 2018:11 Pages 473—481
Checked for plagiarism Yes
Review by Single-blind
Peer reviewers approved by Dr Amy Norman
Peer reviewer comments 3
Editor who approved publication: Dr Scott Fraser
Henry Wamala,1 Leena Aggarwal,1 Anne Bernard,2 Ian A Scott3,4
1Medical Assessment and Planning Unit, Princess Alexandra Hospital, Brisbane, QLD, Australia; 2Queensland Facility for Advanced Bioinformatics, University of Queensland, Brisbane, QLD, Australia; 3Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, QLD, Australia; 4Southside School of Clinical Medicine, University of Queensland, Brisbane, QLD, Australia
Introduction: We compared performance of nine risk scores for coronary heart disease (CHD) among patients presenting to an emergency department (ED) with undifferentiated chest pain of possible coronary origin.
Methods: A retrospective study was undertaken of adult patients presenting with chest pain to atertiary hospital ED with no electrocardiographs or troponin results diagnostic of ischemic chest pain (ICP) or acute coronary syndrome at ED presentation, and no clearly evident noncoronary diagnosis. Risk scores were applied using cut-points distinguishing low- from high-risk patients according to discharge diagnosis of noncardiac chest pain (NCCP) or ICP, respectively. A lower odds ratio (OR) for ICP denoted lower risk for ICP. Score performance was compared using area under receiver–operator characteristic curves (AUC) and predictive values.
Results: A total of 401 patients were studied, of whom 123 (30.7%) had ICP as final diagnosis. Among the nine risk scores, those with greatest ability to detect low-risk patients were The North American Chest Pain Rule (NACPR) score (OR=0.35, 95% CI=0.27–0.46); History, ECG, Age, Risk Factors, and Troponin (HEART) score (OR=0.43; 95% CI=0.35–0.52); and Thrombolysis in Myocardial Infarction (TIMI) score (OR=0.49; 95% CI=0.41–0.58). Discrimination between patients with NCCP and those with ICP was greatest for HEART score (AUC=0.82; 95% CI=0.78–0.86) and lowest for Accelerated Diagnostic Protocol to Assess Patients with Chest Pain Symptoms Using Contemporary Troponins (ADAPT) score (AUC=0.63; 95% CI=0.58–0.69). In excluding ICP, ADAPT had negative predictive value (NPV) 100% (miss rate 0%) but classified only 1.7% of patients as low risk, compared to NACPR with NPV 98% (miss rate 2%), classifying 10.2% as low risk, and HEART with NPV 94% (miss rate 6%), classifying 32.4% as low risk.
Conclusion: The NACPR risk score maximized yield of low-risk patients with lowest miss rate for ICP, while HEART score classified highest proportion of low-risk patients but with a higher miss rate.
Keywords: chest pain, emergency department, risk scores, evaluation, coronary heart disease
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