Background:
Efficient triage of patients presenting to the Emergency Room (ER) with chest pain (CP) is imperative for appropriate delivery of care, decreased length of stay, and reducing cost of care. Several studies have demonstrated the low yield of hospital admission and further testing in the majority of low-risk patients with chest pain. Identification of low-risk patients that could be discharged with outpatient follow-up is the goal. We sought to identify the risk score that maximally identifies low-risk patients and examined the rate of follow-up testing and cardiovascular events in these patients.
Methods:
We retrospectively enrolled 300 consecutive patients who presented to the ER for evaluation of CP. We compared the number of patients stratified as low risk by 3 individual risk scores- the Emergency Department Assessment of Chest Pain Score (EDACS), the HEART (History, ECG, Age, Risk factors and Troponin) score and the TIMI (Thrombolysis in Myocardial Infarction) score and compared their ability to predict major adverse cardiovascular events (MACE) defined as myocardial infarction (MI), percutaneous or surgical coronary revascularization or death, in a 6 week follow-up period. Based on published validation studies, an EDACS score< 16, a HEARTS score≤ 3 and a TIMI score =0 have been identified as the threshold for low-risk. Patients that had a diagnosis of MI on initial presentation or with incomplete records were excluded.
Results:
Among the 300 study patients (mean age 57±5years, 46% male) 45% were smokers, 45% had hyperlipidemia, 60% had hypertension, 22% were diabetic and 27% had a family history of CAD. The EDACS score classified significantly more patients as low risk compared to HEARTS (202/300 vs 150/300-OR of 2.06, CI-1.48-2.86; p<0.0001) and TIMI scores (202/300 vs 127/300- OR 2.80, CI-2.01-3.9; p<0.001). In the study population, 30 patients (10%) underwent coronary CTA, 201 patients (67%) underwent stress testing and 69 patients (23%) were admitted to the observation unit and discharged without further testing. A low-risk EDACS score was present in 93%, 66% and 59% of those undergoing CTA, stress testing and observation admission respectively, suggesting increased use of CTA in low-risk patients. MACE (MI) occurred in one patient identified as high-risk by all scoring systems.
Conclusions:
Among patients presenting to the ER with CP, the EDACS score identifies a larger number of low-risk individuals than other scores. This group may not need inpatient admission or immediate testing. As shown in previous studies, the MACE rate in this ER population is low. Prospective studies comparing these scores in larger populations are warranted.
PREDICTIVE VALUE OF CORONARY ARTERY CALCIFICATION AND THROMBOLYSIS IN MYOCARDIAL INFARCTION RISK SCORE IN THE ASSESSMENT OF PATIENTS WITH ACUTE CHEST PAIN: RESULTS FROM AN EMERGENCY DEPARTMENT REGISTRY