Clinical Prediction Guide
Some risk scores plus high-sensitivity troponin may identify patients with chest pain for early discharge Clinical impact ratings:
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Carlton EW, Khattab A, Greaves K. Identifying patients suitable for discharge after a single-presentation high-sensitivity troponin result: a comparison of five established risk scores and two highsensitivity assays. Ann Emerg Med. 2015;66:635-45.
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Question
Main results
In patients who present to the emergency department with chest pain suggestive of acute coronary syndrome (ACS), do 5 risk models combined with high-sensitivity troponin T (hs-cTnT) or I (hs-cTnI) levels identify patients who are suitable for early discharge?
Of 959 patients, 79 (8.2%) had acute MIs. Operating characteristics for combinations of risk scores and hs-cTnT and/or hs-cTnI levels that met the criteria for clinical utility are in the Table.
Methods
In patients with chest pain suggestive of acute coronary syndrome, some risk models combined with hs-cTnT or hs-cTnI levels achieved clinical utility and may identify patients at low risk for acute myocardial infarction who are suitable for early discharge.
Conclusion
Design: Prospective cohort study with 30 days of follow-up. Setting: Poole National Health Service Foundation Trust, England, UK.
*Information provided by author. Sources of funding: College of Emergency Medicine of the United Kingdom and Bournemouth University. For correspondence: Dr. E.W. Carlton, Bournemouth University, Bournemouth, Dorset, England, UK. E-mail [email protected].
Patients: 959 adults 18 to 79 years of age (mean age 58 y, 59% men) who had ≥ 5 minutes of chest pain suggestive of ACS and for whom the attending physician obtained serial troponin tests. Exclusion criteria included new ST-segment elevation myocardial infarction (MI) or left bundle branch block, cause of chest pain other than ACS, electrocardiogram (ECG) changes indicative of ischemia, arrhythmia, atypical symptoms in the absence of chest discomfort, renal failure requiring dialysis, or other medical conditions requiring hospitalization.
Commentary
The high burden of chest pain evaluation in emergency departments accounts for the recent explosion of research on biomarkers and clinical decision rules for suspected ACS. The paucity of reDescription of prediction guides: Modified Goldman (msearch assessing combined biomarkers and clinical factors or upGoldman) score (typical new onset chest pain at rest, pain simidating previous work with new-generation biomarkers has, until lar to previous MI, no pain relief within 15 min of nitroglycerin, now, been disappointing (1). For settings that have adopted hs-cTn pain duration > 60 min, increase in pain frequency, hypotenassays in chest pain assessment, the study by Carlton and colleagues sion, acute shortness of breath, and pain within 6 wk of MI or and another recent study (2) confirm that this new era of testing reprerevascularization) plus hs-cTnT or hs-cTnI plus nonischemic sents a clear advance in identifying very low-risk patients while shortECG. Thrombolysis in Myocardial Infarction (TIMI) score (age ening admission delays without increasing admissions. ≥ 65 y, ≥ 3 coronary artery disease risk factors, use of aspirin The clinical decision rule literature has reached a state of maturity within 7 d, > 50% coronary stenosis, and ≥ 2 angina events in that should allow it to foster much-needed clinical practice guidepast 24 h) plus hs-cTnT or hs-cTnI plus nonischemic ECG. Global lines addressing some of the intensely wasteful practices related to Registry of Acute Cardiac Events (GRACE) score (Killip Class, syslow-risk chest pain evaluation, especially in settings with harsher tolic blood pressure, heart rate, age, creatinine level, and hsmedicolegal climates or as a means of decision support for riskcTnT or hs-cTnI) plus nonischemic ECG. History, ECG, Age, Risk averse clinicians. The TIMI rule, in particular, has withstood numerous Factors, Troponin (HEART) score (history, ECG results, age, ≥ 3 validations in both confirmed and suspected ACS populations (3). coronary artery disease risk factors, and hs-cTnT or hs-cTnI). Vancouver Chest Pain Rule (hs-cTnT or hs-cTnI, pain upon palpaWhile novel in its approach, the study by Carlton and colleagues tion, and age ≥ 50 y) plus nonischemic ECG. raises concerns around exclusion of patients > 80 years of age and the likelihood of exaggerated test characteristics driven by the inOutcomes: Acute MI within 30 days of hospital visit. A model was corporation of abnormal hs-cTnT into the primary outcome. To deemed to have clinical utility if it could identify > 30% of patients improve generalizability, a systematic review across similar studies who were suitable for early discharge and had negative predictive would be informative, if only to identify a research gap. value {> 99.5%} (upper limit of 95% CI was {> 99.5%}*). Randomized trials that compare combinations of diagnostic strategies, including empirical approaches, and report health economic outTest characteristics of combined risk scores and high-sensitivity troponin comes and downstream excessive investigalevels for identifying patients with acute myocardial infarction (MI) at tions would be welcome next steps. assessment or within 30 d† Eddy Lang, MD Risk scores and Troponin levels Sensitivity Specificity (CI) LRⴙ (CI) LRⴚ (CI) Cumming School of Medicine cutpoints‡ and cutpoints§ (95% CI) University of Calgary M-Goldman ≤ 1 hs-cTnT ≤ 14 ng/L 99% (92 to 100) 43.3% (42.7 to 43.4) 1.7 0.03 Calgary, Alberta, Canada TIMI 0
100% (94 to 100) 35.0% (34.5 to 35.0)
TIMI ≤ 1
1.5
0
95% (87 to 98)
53.5% (52.8 to 53.8)
2.0
0.10
TIMI 0
hs-cTnI ≤ 26.2 ng/L
96% (87 to 99)
35.6% (34.9 to 35.9)
1.5
0.13
HEART ≤ 3
Incorporates hs-cTnI
97% (89 to 100) 34.7% (34.0 to 34.9)
1.5
0.09
†HEART = History, ECG, Age, Risk Factors, Troponin score; hs-cTnT = high-sensitivity troponin T; hs-cTnI = high-sensitivity troponin I; M-Goldman = Modified Goldman; TIMI = Thrombolysis in Myocardial Infarction score; other abbreviations defined in Glossary. Of 959 patients, 79 (8.2%) had acute MIs. ‡Table includes risk scores with the potential to identify > 30% of patients as suitable for immediate discharge with a negative predictive value {> 99.5% (upper limit of 95% CI is > 99.5%)}*. §Values above these cutpoints will identify all or almost all patients with acute MI at visit or within the next 30 d. For example, patients with scores over TIMI 0 will include all those with acute MI.
References 1. Worster A, Kavsak PA, Brown M. Risk stratification in the era of high-sensitivity troponin assays. Ann Emerg Med. 2012;59:126-7. 2. Crowder KR, Jones TD, Lang ES, et al. The impact of high-sensitivity troponin implementation on hospital operations and patient outcomes in 3 tertiary care centers. Am J Emerg Med. 2015. 3. Hess EP, Agarwal D, Chandra S, et al. Diagnostic accuracy of the TIMI risk score in patients with chest pain in the emergency department: a meta-analysis. CMAJ. 2010;182: 1039-44.
doi:10.7326/ACPJC-2016-164-4-022
姝 2016 American College of Physicians
JC22
ACP Journal Club
Downloaded From: http://annals.org/ by a University of California San Diego User on 01/04/2017
Annals of Internal Medicine
16 Feb 2016
Some risk scores plus high-sensitivity troponin may identify patients with chest pain for early discharge Clinical impact ratings:
多多多多多多夞
多多多多多夞夞
Carlton EW, Khattab A, Greaves K. Identifying patients suitable for discharge after a single-presentation high-sensitivity troponin result: a comparison of five established risk scores and two highsensitivity assays. Ann Emerg Med. 2015;66:635-45.
多多多多多夞夞
Question
Main results
In patients who present to the emergency department with chest pain suggestive of acute coronary syndrome (ACS), do 5 risk models combined with high-sensitivity troponin T (hs-cTnT) or I (hs-cTnI) levels identify patients who are suitable for early discharge?
Of 959 patients, 79 (8.2%) had acute MIs. Operating characteristics for combinations of risk scores and hs-cTnT and/or hs-cTnI levels that met the criteria for clinical utility are in the Table.
Methods
In patients with chest pain suggestive of acute coronary syndrome, some risk models combined with hs-cTnT or hs-cTnI levels achieved clinical utility and may identify patients at low risk for acute myocardial infarction who are suitable for early discharge.
Conclusion
Design: Prospective cohort study with 30 days of follow-up. Setting: Poole National Health Service Foundation Trust, England, UK.
*Information provided by author. Sources of funding: College of Emergency Medicine of the United Kingdom and Bournemouth University. For correspondence: Dr. E.W. Carlton, Bournemouth University, Bournemouth, Dorset, England, UK. E-mail [email protected].
Patients: 959 adults 18 to 79 years of age (mean age 58 y, 59% men) who had ≥ 5 minutes of chest pain suggestive of ACS and for whom the attending physician obtained serial troponin tests. Exclusion criteria included new ST-segment elevation myocardial infarction (MI) or left bundle branch block, cause of chest pain other than ACS, electrocardiogram (ECG) changes indicative of ischemia, arrhythmia, atypical symptoms in the absence of chest discomfort, renal failure requiring dialysis, or other medical conditions requiring hospitalization.
Commentary
The high burden of chest pain evaluation in emergency departments accounts for the recent explosion of research on biomarkers and clinical decision rules for suspected ACS. The paucity of reDescription of prediction guides: Modified Goldman (msearch assessing combined biomarkers and clinical factors or upGoldman) score (typical new onset chest pain at rest, pain simidating previous work with new-generation biomarkers has, until lar to previous MI, no pain relief within 15 min of nitroglycerin, now, been disappointing (1). For settings that have adopted hs-cTn pain duration > 60 min, increase in pain frequency, hypotenassays in chest pain assessment, the study by Carlton and colleagues sion, acute shortness of breath, and pain within 6 wk of MI or and another recent study (2) confirm that this new era of testing reprerevascularization) plus hs-cTnT or hs-cTnI plus nonischemic sents a clear advance in identifying very low-risk patients while shortECG. Thrombolysis in Myocardial Infarction (TIMI) score (age ening admission delays without increasing admissions. ≥ 65 y, ≥ 3 coronary artery disease risk factors, use of aspirin The clinical decision rule literature has reached a state of maturity within 7 d, > 50% coronary stenosis, and ≥ 2 angina events in that should allow it to foster much-needed clinical practice guidepast 24 h) plus hs-cTnT or hs-cTnI plus nonischemic ECG. Global lines addressing some of the intensely wasteful practices related to Registry of Acute Cardiac Events (GRACE) score (Killip Class, syslow-risk chest pain evaluation, especially in settings with harsher tolic blood pressure, heart rate, age, creatinine level, and hsmedicolegal climates or as a means of decision support for riskcTnT or hs-cTnI) plus nonischemic ECG. History, ECG, Age, Risk averse clinicians. The TIMI rule, in particular, has withstood numerous Factors, Troponin (HEART) score (history, ECG results, age, ≥ 3 validations in both confirmed and suspected ACS populations (3). coronary artery disease risk factors, and hs-cTnT or hs-cTnI). Vancouver Chest Pain Rule (hs-cTnT or hs-cTnI, pain upon palpaWhile novel in its approach, the study by Carlton and colleagues tion, and age ≥ 50 y) plus nonischemic ECG. raises concerns around exclusion of patients > 80 years of age and the likelihood of exaggerated test characteristics driven by the inOutcomes: Acute MI within 30 days of hospital visit. A model was corporation of abnormal hs-cTnT into the primary outcome. To deemed to have clinical utility if it could identify > 30% of patients improve generalizability, a systematic review across similar studies who were suitable for early discharge and had negative predictive would be informative, if only to identify a research gap. value {> 99.5%} (upper limit of 95% CI was {> 99.5%}*). Randomized trials that compare combinations of diagnostic strategies, including empirical approaches, and report health economic outTest characteristics of combined risk scores and high-sensitivity troponin comes and downstream excessive investigalevels for identifying patients with acute myocardial infarction (MI) at tions would be welcome next steps. assessment or within 30 d† Eddy Lang, MD Risk scores and Troponin levels Sensitivity Specificity (CI) LRⴙ (CI) LRⴚ (CI) Cumming School of Medicine cutpoints‡ and cutpoints§ (95% CI) University of Calgary M-Goldman ≤ 1 hs-cTnT ≤ 14 ng/L 99% (92 to 100) 43.3% (42.7 to 43.4) 1.7 0.03 Calgary, Alberta, Canada TIMI 0
100% (94 to 100) 35.0% (34.5 to 35.0)
TIMI ≤ 1
1.5
0
95% (87 to 98)
53.5% (52.8 to 53.8)
2.0
0.10
TIMI 0
hs-cTnI ≤ 26.2 ng/L
96% (87 to 99)
35.6% (34.9 to 35.9)
1.5
0.13
HEART ≤ 3
Incorporates hs-cTnI
97% (89 to 100) 34.7% (34.0 to 34.9)
1.5
0.09
†HEART = History, ECG, Age, Risk Factors, Troponin score; hs-cTnT = high-sensitivity troponin T; hs-cTnI = high-sensitivity troponin I; M-Goldman = Modified Goldman; TIMI = Thrombolysis in Myocardial Infarction score; other abbreviations defined in Glossary. Of 959 patients, 79 (8.2%) had acute MIs. ‡Table includes risk scores with the potential to identify > 30% of patients as suitable for immediate discharge with a negative predictive value {> 99.5% (upper limit of 95% CI is > 99.5%)}*. §Values above these cutpoints will identify all or almost all patients with acute MI at visit or within the next 30 d. For example, patients with scores over TIMI 0 will include all those with acute MI.
References 1. Worster A, Kavsak PA, Brown M. Risk stratification in the era of high-sensitivity troponin assays. Ann Emerg Med. 2012;59:126-7. 2. Crowder KR, Jones TD, Lang ES, et al. The impact of high-sensitivity troponin implementation on hospital operations and patient outcomes in 3 tertiary care centers. Am J Emerg Med. 2015. 3. Hess EP, Agarwal D, Chandra S, et al. Diagnostic accuracy of the TIMI risk score in patients with chest pain in the emergency department: a meta-analysis. CMAJ. 2010;182: 1039-44.
doi:10.7326/ACPJC-2016-164-4-022
姝 2016 American College of Physicians
JC22
ACP Journal Club
Downloaded From: http://annals.org/ by a University of California San Diego User on 01/04/2017
Annals of Internal Medicine
16 Feb 2016
