scholarly journals Evaluation and comparison of six GRACE models for the stratification of undifferentiated chest pain in the emergency department

2020 ◽  
Author(s):  
Wen Zheng ◽  
Guangmei Wang ◽  
Jingjing Ma ◽  
Shuo Wu ◽  
He Zhang ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Emergency Department ◽  
Chest Pain ◽  
Comprehensive Evaluation ◽  
Acute Chest Pain ◽  
Public Hospitals ◽  
Cardiac Events ◽  
Coronary Syndrome ◽  
Coronary Events ◽  
Grace Score

Abstract Background: The Global Registry of Acute Coronary Events (GRACE) score is recommended for stratifying chest pain. However, there are six formulas used to calculate the GRACE score for different outcomes of acute coronary syndrome (ACS), including death (Dth) or composite of death and myocardial infarction (MI), while in hospital (IH), within 6 months after discharge (OH6m) or from admission to 6 months later (IH6m). We aimed to perform the first comprehensive evaluation and comparison of six GRACE models to predict 30-day major adverse cardiac events (MACEs) in patients with acute chest pain in the emergency department (ED). Methods: Patients with acute chest pain were consecutively recruited from August 24, 2015 to September 30, 2017 from the EDs of two public hospitals in China. The 30-day MACEs included death, acute myocardial infarction (AMI), emergency revascularization, cardiac arrest and cardiogenic shock. The correlation, calibration, discrimination, reclassification and diagnostic accuracy at certain cutoff values of six GRACE models were evaluated. Comparisons with the History, ECG, Age, Risk Factors, and Troponin (HEART) and Thrombolysis in Myocardial Infarction (TIMI) scores were conducted. Results: A total of 2886 patients were analyzed, with 590 (20.4%) patients experiencing outcomes. The GRACE(IHDthMI), GRACE(IH6mDthMI), GRACE(IHDth), GRACE(IH6mDth), GRACE(OH6mDth) and GRACE(OH6mDthMI) showed positive linear correlations with the actual MACE rates (r≥0.568, p<0.001). All these models had good calibration (Hosmer-Lemeshow test, p≥0.073) except GRACE(IHDthMI) (p<0.001). The corresponding C-statistics were 0.83(0.81,0.84), 0.82(0.81,0.83), 0.75(0.73,0.76), 0.73(0.72,0.75), 0.72(0.70,0.73) and 0.70(0.68,0.71), respectively, first two of which were comparable to HEART (0.82, 0.80-0.83) and superior to TIMI (0.71, 0.69-0.73). With a sensitivity ≥95%, GRACE(IHDthMI) ≤81 and GRACE(IH6mDthMI) ≤79 identified 868(30%) and 821(28%) patients as low risk, respectively, which were significantly better than other GRACEs and HEART ≤3(22%). With a specificity ≥95%, GRACE(IHDthMI) >186 and GRACE(IH6mDthMI) >161 could recognize 12% and 11% patients as high risk, which were greater than other GRACEs, HEART ≥8(9%) and TIMI ≥5(8%). Conclusions: In this Chinese setting, certain strengths of GRACE models beyond HEART and TIMI scores were still noteworthy for stratifying chest pain patients. The validation and reasonable application of appropriate GRACE models in the evaluation of undifferentiated chest pain should be recommended.

scholarly journals Evaluation and comparison of six GRACE models to stratify undifferentiated chest pain at the emergency department

2019 ◽  
Author(s):  
Wen Zheng ◽  
Guangmei Wang ◽  
Jingjing Ma ◽  
Shuo Wu ◽  
He Zhang ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Emergency Department ◽  
Chest Pain ◽  
Goodness Of Fit ◽  
Acute Chest Pain ◽  
Public Hospitals ◽  
Cardiac Events ◽  
Goodness Of Fit Test ◽  
Coronary Syndrome ◽  
Grace Score

Abstract Background The Global Registry of Acute Coronary Events (GRACE) score is recommended for stratifying chest pain. However, there are six formulas used to calculate the GRACE score for different outcomes of acute coronary syndrome (ACS), including death (Dth) or composite of death and myocardial infarction (MI), during in hospital (IH), in 6 months after discharge (OH6m) or from admission to 6 months later (IH6m). The more appropriate one for stratification of undifferentiated chest pain remains unclear. We aimed to provide firstly comprehensive evaluation and comparison of six GRACE models to predict 30-day major adverse cardiac events (MACE) in acute chest pain at the emergency department (ED). Methods Patients with acute chest pain were consecutively recruited from August 24, 2015 to September 30, 2017 in EDs of two public hospitals in China. The primary outcome was MACE within 30 days, including death, acute myocardial infarction (MI), emergency revascularization, cardiac arrest and cardiogenic shock. GRACE scores were calculated retrospectively using the prospectively obtained data. Correlation, calibration, discrimination and reclassification of six GRACE models were evaluated. Results A total of 2886 patients were analyzed, with 590 (20.4%) patients getting outcomes. The GRACE (IH6mDthMI), GRACE (IHDthMI), GRACE (IHDth), GRACE (IH6mDth), GRACE (OH6mDth) and GRACE (OH6mDthMI) showed positive linear correlation with actual MACE rates (r≥0.568, p<0.001), first two of which exerted very strong relationships (r>0.9). All these models had good calibration (Hosmer-Lemeshow goodness-of-fit test, p≥0.073) except GRACE (IHDthMI) (p<0.001). The corresponding c-statistics were 0.82(0.81,0.83), 0.83(0.81,0.84), 0.75(0.73,0.76), 0.73(0.72,0.75), 0.72(0.70,0.73) and 0.70(0.68,0.71). Improvement in AUC, NRI and IDI (p<0.001) represented that GRACE (IH6mDthMI) and GRACE (IHDthMI) were superior to other four models in discrimination and reclassification. Conclusions The GRACE (IH6mDthMI) and GRACE (IHDthMI) outperformed other GRACE models in discriminating high or low-risk of 30-day MACE in patients with chest pain. The reasonable application of appropriate GRACE models should be recommended on stratification of undifferentiated chest pain presenting to the ED.

Abstract 681: Characteristics of Atherosclerotic Plaque Burden in Patients With and Without Acute Coronary Syndrome Presenting With Acute Chest Pain to the Emergency Department

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Fabian Bamberg ◽  
Maros Ferecik ◽  
Quynh Truong ◽  
Ian Rogers ◽  
Michael Shapiro ◽  
...  
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Coronary Arteries ◽  
Atherosclerotic Plaque ◽  
Acute Chest Pain ◽  
Coronary Plaque ◽  
Plaque Burden ◽  
Coronary Syndrome ◽  
Coronary Ct ◽  
Calcified Plaque

Background: Coronary computed tomography (CT) may improve the early triage of patients with acute chest pain in the emergency department (ED). The aim of this study was to compare the presence and extent of coronary atherosclerotic plaque as detected by coronary CT in patients with and without acute coronary syndromes (ACS). Methods: The study was designed as a prospective, observational cohort study in patients with acute chest pain but negative cardiac biomarkers and no diagnostic ECG changes, admitted to rule out myocardial ischemia. All patients underwent coronary CT prior to hospital admission. The presence of coronary plaque was treated as a dichotomous outcome, and the extent of CAD was defined as number of (1) coronary segments with plaque, or (2) major coronary arteries with plaque detected by MDCT as assessed by two independent observers. The clinical outcome (ACS) was adjudicated by a review committee using established AHA criteria; subjects with history of CAD (stent placement, bypass) were excluded. Results : Among 368 patients with acute chest pain (mean age 53±12 years, 61% male) 31 patients were determined to have ACS (8%). None of the 183 subjects without plaque (50%) had an ACS. Among the remaining 185 subjects (mean age 58.0±11.5 years, 68% male) in whom coronary plaque was detected, patients with ACS had a significantly more plaque (7.2±3.7 vs. 4.2±3.4, p<0.0001 segments) as compared to subjects without ACS. Similar results were seen for calcified plaque and non-calcified plaque (6.5±3.7 vs. 3.6±3.5 segments, p<0.0001; and 3.6±3.2 vs. 1.8±2.2 segments, p<0.0001, respectively). In addition, the rate of ACS increased with the number of major coronary arteries with plaque (1-vessel: 6.8%, 2-vessels: 10.6%, 3 vessels: 30.8%, and 4-vessels: 25%; p<0.01). In contrast, the ratio of non-calcified to calcified plaque was not different between patients with and without ACS (0.68±0.6 vs. 0.54±0.72, p=0.31). Conclusions: The extent of coronary plaque differs between subjects with and without ACS among patients presenting with acute chest pain. Detailed assessment of the extent and composition of coronary plaque may be helpful to assess risk of ACS among patients with acute chest pain but inconclusive initial ED evaluation.

Development of a Clinical Prediction Rule for 30-Day Cardiac Events in Emergency Department Patients With Chest Pain and Possible Acute Coronary Syndrome

2012 ◽  
Vol 59 (2) ◽  
pp. 115-125.e1 ◽  
Author(s):  
Erik P. Hess ◽  
Robert J. Brison ◽  
Jeffrey J. Perry ◽  
Lisa A. Calder ◽  
Venkatesh Thiruganasambandamoorthy ◽  
...  
Keyword(s):  
Emergency Department ◽  
Acute Coronary Syndrome ◽  
Chest Pain ◽  
Prediction Rule ◽  
Clinical Prediction Rule ◽  
Clinical Prediction ◽  
Cardiac Events ◽  
Coronary Syndrome ◽  
Emergency Department Patients

Abstract 16639: Low Yield of Additional Non-invasive Testing in Moderate Worst Stenosis by cCTA in Acute Chest Pain Patients - Results From a Clinical ED cCTA Registry

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Sumbal A Janjua ◽  
Harshna V Vadvala ◽  
Pedro V Staziaki ◽  
Richard A Takx ◽  
Anand M Prabhakar ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Chest Pain ◽  
Unstable Angina ◽  
Acute Chest Pain ◽  
Left Ventricular ◽  
Fractional Flow ◽  
Coronary Syndrome ◽  
Non Invasive ◽  
Lipid Rich Plaque ◽  
Pain Patients

Introduction: Coronary computed tomography angiography (cCTA) allows efficient triage of low-intermediate risk patients with suspected acute coronary syndrome (ACS); appropriate management of patients with moderate stenosis by cCTA is unknown. We evaluated the yield of downstream testing in moderate stenosis patients in a clinical ED cCTA registry. Methods: All consecutive ED patients with acute chest pain undergoing cCTA as part of routine care between October 2012 and July 2014 were screened. Patients with moderate as their worst stenosis (50-69% stenosis) on cCTA were included. Plaque characteristics, resting left ventricular function (by cCTA), results of any functional downstream non-invasive testing, invasive coronary angiography (ICA) and interventions, and discharge diagnosis were reported. ACS was defined as acute myocardial infarction (MI) or unstable angina pectoris (UAP) and adjudicated by an independent committee. Ischemia was defined as clear, territorial abnormality by myocardial perfusion scintigraphy imaging (MPI) or rest or stress echocardiogram, significant dynamic ST-T shift by exercise treadmill test (ETT) and stenosis >70% on ICA or fractional flow reserve (FFR) <0.75. Results: 586 patients underwent cCTA, with 7.2% (n=42) deemed moderate stenosis. Rate of ACS was 14.2% (n=6) with all adjudicated as UAP. Of these, 83% had stenosis caused by lipid-rich plaque; 33% had wall motion abnormalities on cCTA. The majority (n=28; 66%) underwent downstream non-invasive testing. Overall, n=2 (6%) of the non-invasive tests were positive for ischemia while n=3 (42%) of the invasive tests were diagnosed as positive for ischemia (all revascularized) (Figure 1). Conclusions: Unstable angina but not myocardial infarction is frequent among acute chest pain patients with moderate stenosis by cCTA. cCTA findings of lipid-rich plaque and resting functional abnormalities had a relatively higher yield vs. other non-invasive tests to detect ischemia.

Risk stratifying chest pain patients in the emergency department using HEART, GRACE and TIMI scores, with a single contemporary troponin result, to predict major adverse cardiac events

2018 ◽  
Vol 35 (7) ◽  
pp. 420-427 ◽  
Author(s):  
Peter D W Reaney ◽  
Hamish I Elliott ◽  
Awsan Noman ◽  
Jamie G Cooper
Keyword(s):  
Chest Pain ◽  
High Sensitivity ◽  
Tertiary Hospital ◽  
Low Risk ◽  
Cardiac Events ◽  
Heart Score ◽  
Coronary Syndrome ◽  
C Statistic ◽  
Diagnostic Characteristics ◽  
Coronary Events

BackgroundThe majority of patients presenting to the ED with cardiac sounding chest pain have a non-diagnostic ECG and the problem of differentiating those suffering an acute coronary syndrome from those without is familiar to all ED clinical staff. To stratify risk in these patients, specific scores have been developed. Recent work has focused on incorporating newer high-sensitivity cardiac troponin (hs-cTn) assays; however, issues regarding performance and availability of these assays remain.AimProspectively compare HEART, Global Registry of Acute Coronary Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) scores, using a single contemporary cTn at admission, to predict a major adverse cardiac event (MACE) at 30 days.MethodProspective observational cohort study performed in a UK tertiary hospital in patients with suspected cardiac chest pain and no significant ST elevation on initial ECG. Data collection took place 2 December 2014 to 8 February 2016. The treating clinician recorded risk score data real time and a single contemporary cTn taken at presentation was used in score calculation. The primary endpoint was 30-day MACE. C-statistic was determined for each score and diagnostic characteristics of high-risk and low-risk cut-offs were calculated.Results189/1000 patients in the study developed a 30-day MACE. The c-statistic of HEART for 30-day MACE (0.87 (95% CI 0.84 to 0.90)) was higher than TIMI (0.78 (95% CI 0.74 to 0.81)) and GRACE (0.74 (95% CI 0.70 to 0.78)).HEART score ≤3 identified low-risk patients with sensitivity 99.5% (95% CI 97.1% to 99.9%) and negative predictive value (NPV) 99.6% (95% CI 97.3% to 99.9%) exceeding TIMI 0 (sensitivity 97.4% (95% CI 93.9% to 99.1%) and NPV 97.8% (95% CI 94.8% to 99.1%)) and GRACE score 0–55 (sensitivity 95.2% (95% CI 91.1% to 97.8%) and NPV 95.8% (95% CI 92.2% to 97.7%)).ConclusionHEART outperformed both TIMI and GRACE in overall discriminative capacity for 30-day MACE. Using a single contemporary cTn at presentation, a HEART score of ≤3 demonstrated sensitivity and NPV of ≥99.5% for 30-day MACE. These results reach the threshold for a safe discharge strategy but should be interpreted thoughtfully in light of other work.

scholarly journals Prognostic Value of CT Angiography for Major Adverse Cardiac Events in Patients With Acute Chest Pain From the Emergency Department

2011 ◽  
Vol 4 (5) ◽  
pp. 481-491 ◽  
Author(s):  
Christopher L. Schlett ◽  
Dahlia Banerji ◽  
Emily Siegel ◽  
Fabian Bamberg ◽  
Sam J. Lehman ◽  
...  
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Ct Angiography ◽  
Prognostic Value ◽  
Acute Chest Pain ◽  
Major Adverse Cardiac Events ◽  
Cardiac Events ◽  
Adverse Cardiac Events
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