Angina scale، Risk scales in the diagnosis of unstable angina in patients with chest pain with electrocardiogram and negative biomarkers Risk scales in the diagnosis of unstable angina in patients with chest pain with negative electrocardiogram and biomarkers ☆
Author links open overlay panel John Sprockel Díaz Magda Lorena González Russi Rafael Barón
The evaluation of chest pain with electrocardiogram and negative biomarkers represents a challenge for the clinician. As an additional strategy, several scales are used for prognostic stratification. We describe the diagnostic performance of these scales for acute coronary syndromes in high probability patients, with electrocardiogram and negative biomarkers.
Study of diagnostic tests in a cohort of patients older than 18 years admitted to 2 tertiary hospitals for chest pain and suspected acute coronary syndrome, without electrocardiographic changes or elevation of biomarkers. As a diagnostic reference, various coronary stratification tests were used and for the index test the different scales were included for the evaluation of the prognosis in chest pain. The operating characteristics were calculated at different cutting points and the areas under the ROC curve were compared.
We included 86 patients whose average age was 63 years (SD: 12); 61.6% were men and 51.2% had a diagnosis of angina. The HEART scale had the best performance, with an area under the curve of 0.65, followed by the GRACE with 0.61. The confidence intervals were superimposed between the different scales evaluated.
The risk prediction scales in patients with chest pain, evaluated for diagnostic purposes, showed poor discriminatory power in a population of high-risk patients despite having a negative electrocardiogram and troponin.
The evaluation of chest pain in cases where electrocardiogram and biomarkers are negative represent a challenge for the clinician. Severe scales are used as an additional strategy for the prognosis stratification. The objective of this study is to describe the diagnostic performance of the diagnostic scales for acute coronary symptoms in patients with high probability and in whom the electrocardiogram and biomarkers are negative.
A study of the diagnostic tests in a cohort of patients older than 18 years old, who were admitted into 2 level-3 hospitals due to chest pain and suspicion of acute coronary syndrome with no changes in the electrocardiogram or increases in biomarkers. Different coronary stratification tests were used as a diagnostic reference, and the different scales for evaluating the prognosis in chest pain were included for the index test. The operational characteristics were calculated for different cut-off points, and the areas under the ROC curve were compared.
The study included a total of 86 patients. The mean age was 63 years old, with 61.6% men, and 51.2% of the patients had a diagnosis of angina. The HEART scale gave a better performance, with an area under the curve of 0.65, followed by the GRACE scale with 0.61. The confidence intervals overlapped the different evaluation scales.
The scales of risk predicted in patients with chest pain, evaluated for diagnostic purposes, showed a lower discriminatory power in a population of patients with high risk, despite having a negative electrocardiogram and troponin.
Thoracic pain represents the second cause of consultation in the emergency services according to a survey conducted in 2006 by the NHAMCS in the USA. UU 1 . Of these cases, less than 5% represent an infarction with ST elevation and around 20% are due to acute coronary syndromes (ACS) without ST elevation 2 . Most of the time, chest pain is caused by other conditions 3 , which are often benign. During the evaluation, it is important to discard ACS, which entails the consumption of a large amount of resources 4 .
Therefore, an aspect that has been considered fundamental in the assessment of chest pain is the correct identification of patients with low risk to develop cardiovascular adverse events, in order to discharge them from the emergency service in an early and safe manner, to reduce congestion and limit the need for unnecessary hospitalizations, with the economic burden that this entails 2 . Although the incursion of highly sensitive troponins in recent years has favored making fewer errors when unloading patients, 5 the final guidelines in this direction are not yet perfectly established.
That is why they have tried to develop and apply various scales to assess the risk of cardiovascular events, some of them extrapolated from their experience with ACS, applied to evaluate chest pain, such as TIMI, GRACE 6 , 7 and a variation of the TIMI with 3 of its variables called CARdiac 8 ; others, designed specifically for low-probability thoracic pain such as that of Florencia 9 and Sanchís 10 and one for a more diverse population of chest pain, HEART 11 . All of them have been shown to increase the discriminatory power of troponin.
The aim of this study is to evaluate the performance of various risk scales for the diagnosis of ACS in patients without electrocardiographic ischemic changes or elevation of troponin levels.
A study of diagnostic tests was carried out in a prospective cohort in which patients over 18 years of age who were admitted for chest pain with suspected ACS were included in a consecutive manner, in which no electrocardiographic ischemic changes were observed (segment deviation ST of more than 0.5 mm, changes of the T wave or presence of pathological Q waves in 2 or more leads) or elevation of troponin, hospitalized in the Emergency Department or in the Coronary Care Unit of 2 university hospitals of third level of care, the Hospital de San José and the University Children’s Hospital of San José, both located in Bogotá, during the period between June 1, 2014 and February 29, 2016.
The reference standard for diagnosis consisted of different strategies of invasive coronary stratification (coronary arteriography) or noninvasive imaging (myocardial perfusion or echoestrés) performed during the patient’s hospitalization in any of the hospital’s services. In addition, some cases were taken into account in which the diagnostic assignment of other causes of chest pain, for example, a chest tomography for a pulmonary embolism, was achieved unequivocally through some other diagnostic means.