Comparison of nine coronary risk scores in evaluating patients presenting to hospital with undifferentiated chest pain

Figures & data

Table

• HEART (History, ECG, Age, Risk Factors, and Troponin)^Citation14

• ADAPT (Accelerated Diagnostic Protocol to Assess Patients with Chest Pain Symptoms Using Contemporary Troponins)^Citation15

• EDACS (Emergency Department Assessment of Chest Pain Score)^Citation16

• NACPR (The North American Chest Pain Rule)^Citation17

• TIMI (Thrombolysis in Myocardial Infarction)^Citation18

• m.TIMI (modified TIMI)^Citation19

• GRACE (Global Registry of Acute Coronary Events)^Citation20

• PURSUIT (Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy)^Citation21

• FPR (Florence Prediction Rule)^Citation22

Table 1 Patient characteristics

Variable	Total cohort (n=401)	NCCP (n=278)	ICP (n=123)	P-valuea
Mean age, years (±SD)	61.5 (14.3)	58.6 (13.3)	65.8 (14.2)	<0.001
Male	242 (60.3%)	159 (57.2%)	83 (67.5%)	0.059
Cardiovascular risk factors
Hypertension	245 (61.1%)	151 (54.3%)	94 (76.4%)	<0.001
Diabetes mellitus	97 (24.2%)	61 (21.9%)	36 (29.3%)	0.129
Dyslipidemia	213 (53.1%)	121 (43.5%)	92 (74.8%)	<0.001
Current smoker	66 (16.5%)	49 (17.6%)	17 (13.8%)	0.6552
History of CHD	168 (41.9%)	79 (28.4%)	89 (72.4%)	<0.001
PVD	40 (10.0%)	12 (4.3%)	28 (22.8%)	<0.001
Chronic kidney disease	52 (13.0%)	20 (7.2%)	32 (26.0%)	<0.001
Family history of CHD	45 (11.2%)	29 (10.4%)	16 (13.0%)	0.493
Investigations performedb
Exercise ECG test	25 (6.2%) – 1+	22 (7.9%) – 0+	3 (2.4%) – 1+	0.043
Stress echocardiograph	14 (5.0%) – 1+	14 (5.0%) – 1+	0 (0%) – 0+	0.007
Stress MPS	7 (1.7%) – 1+	4 (1.4%) – 0+	3 (2.4%) – 1+	0.443
CTCA	26 (6.5%) – 1+	23 (8.3%) – 0+	3 (2.4%) – 1+	0.028
ICA	27 (6.7%) – 17+	8 (2.9%) – 4+	19 (15.4%) – 13+	<0.001

Notes:

a Comparing NCCP and ICP groups.

b Number (%) of patients undergoing investigation – number of patients with positive result for CHD.

Abbreviations: CHD, coronary heart disease; CTCA, computerized tomography of coronary arteries; ECG, electrocardiograph; ICA, invasive coronary angiography; ICP, ischemic chest pain; MPS, myocardial perfusion scan; NCCP, noncardiac chest pain; ND, not done; PVD, peripheral vascular disease.

Table 2 Values of risk scores according to high or low risk as defined by final discharge diagnosis or by risk score cut-point

Risk category: high or low according to final discharge diagnosisa	Values of risk score, mean (±SD)	Risk category: high or low according to risk score cut-pointb	Patients identified by risk score as being low or high risk, n (%)
FPR		FPR
High risk	4.29 (1.5)	High risk	344 (85.89)
Low risk	3.38 (1.79)	Low risk	57 (14.2%)
PURSUIT		PURSUIT
High risk	11.16 (3.31)	High risk	223 (55.4%)
Low risk	7.76 (4.62)	Low risk	178 (44.6%)
GRACE		GRACE
High risk	123.41 (38.32)	High risk	211 (52.6%)
Low risk	96.12 (29.63)	Low risk	190 (47.4%)
m.TIMI		m.TIMI
High risk	4.19 (2.47)	High risk	218 (54.4%)
Low risk	2.12 (2.12)	Low risk	183 (45.6%)
TIMI		TIMI
High risk	3.73 (1.4)	High risk	227 (56.6%)
Low risk	2.05 (1.53)	Low risk	174 (43.4%)
ADAPT		ADAPT
High risk	4.57 (1.62)	High risk	394 (98.3%)
Low risk	3.62 (1.95)	Low risk	7 (1.7%)
NACPR		NACPR
High risk	2.25 (0.78)	High risk	360 (89.8%)
Low risk	1.42 (0.93)	Low risk	41 (10.2%)
EDACS		EDACS
High risk	19.06 (5.82)	High risk	226 (56.4%)
Low risk	13.86 (6.27)	Low risk	175 (43.6%)
HEART		HEART
High risk	5.74 (1.76)	High risk	271 (67.6%)
Low risk	3.64 (1.52)	Low risk	130 (32.4%)

Notes:

a Low risk defined as final discharge diagnosis of NCCP (n=124); high risk defined as final discharge diagnosis of ICP (n=277).

b Cut-points for each score used to categorize low- vs high-risk patients are listed in Supplementary material S1.

Abbreviations: ADAPT, Accelerated Diagnostic Protocol to Assess Patients with Chest Pain Symptoms Using Contemporary Troponins; EDACS, Emergency Department Assessment of Chest Pain Score; HEART, History, ECG, Age, Risk Factors, and Troponin; FPR, Florence Prediction Rule; GRACE, Global Registry of Acute Coronary Events; m.TIMI, modified TIMI; NACPR, The North American Chest Pain Rule; NCCP, noncardiac chest pain; PURSUIT, Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy; TIMI, Thrombolysis in Myocardial Infarction.

Table 3 Predictive accuracy for identifying low-risk vs high-risk patients

Risk score	OR	95% CI
NACPR	0.35	0.27–0.46
HEART	0.43	0.35–0.52
TIMI	0.49	0.41–0.58
m.TIMI	0.69	0.62–0.76
FPR	0.72	0.62–0.82
ADAPT	0.76	0.67–0.85
PURSUIT	0.80	0.74–0.85
EDACS	0.87	0.84–0.91
GRACE	0.98	0.97–0.98

Note: A lower OR means a lower likelihood of ICP as discharge diagnosis and therefore higher likelihood of NCCP, which classifies patients as low risk.

Abbreviations: ADAPT, Accelerated Diagnostic Protocol to Assess Patients with Chest Pain Symptoms Using Contemporary Troponins; EDACS, Emergency Department Assessment of Chest Pain Score; HEART, History, ECG, Age, Risk Factors, and Troponin; FPR, Florence Prediction Rule; GRACE, Global Registry of Acute Coronary Events; ICP, ischemic chest pain; m.TIMI, modified TIMI; NACPR, The North American Chest Pain Rule; NCCP, noncardiac chest pain; OR, odds ratio; PURSUIT, Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy; TIMI, Thrombolysis in Myocardial Infarction.

Table 4 AUC for different risk scores

Risk score	AUC	95% CI
HEART	0.82	0.78–0.86
TIMI	0.78	0.74–0.83
m.TIMI	0.76	0.71–0.81
NACPR	0.74	0.70–0.79
PURSUIT	0.72	0.66–0.77
EDACS	0.72	0.67–0.77
GRACE	0.71	0.66–0.77
FPR	0.65	0.59–0.70
ADAPT	0.63	0.58–0.69

Abbreviations: ADAPT, Accelerated Diagnostic Protocol to Assess Patients with Chest Pain Symptoms Using Contemporary Troponins; AUC, area under the curve; EDACS, Emergency Department Assessment of Chest Pain Score; HEART, History, ECG, Age, Risk Factors, and Troponin; FPR, Florence Prediction Rule; GRACE, Global Registry of Acute Coronary Events; m.TIMI, modified TIMI; NACPR, The North American Chest Pain Rule; PURSUIT, Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy; TIMI, Thrombolysis in Myocardial Infarction.

Table 5 Sensitivity, specificity, likelihood ratios, and predictive values for different risk scores

Risk score	Sensitivity	Specificity	LR+	LR−	PPV	NPV	Miss rate
HEART	93% (89%–98%)	48% (42%–54%)	1.80 (1.58–2.04)	0.14 (0.07–0.27)	46% (40%–52%)	94% (90%–98%)	6% (4%–9%)
TIMI	84% (78%–91%)	61% (55%–67%)	2.16 (1.82–2.57)	0.26 (0.17–0.39)	51% (44%–58%)	89% (84%–94%)	11% (8%–14%)
m.TIMI	76% (71%–86%)	62% (56%–68%)	2.06 (1.71–2.47)	0.35 (0.24–0.50)	50% (42%–57%)	86% (81%–91%)	14% (11%–18%)
NACPR	99% (98%–100%)	16% (11%–20%)	1.18 (1.11–1.24)	0.05 (0.01–0.38)	34% (31%–41%)	98% (93%–102%)	2% (1%–4%)
PURSUIT	71% (63%–79%)	57% (51%–63%)	1.64 (1.37–1.97)	0.51 (0.38–0.69)	44% (37%–51%)	80% (75%–86%)	20% (16%–24%)
EDACS	74% (66%–81%)	56% (50%–62%)	1.68 (1.41—2.01)	0.47 (0.34–0.64)	45% (38%–51%)	82% (76%–87%)	18% (14%–22%)
GRACE	67% (59%–75%)	59% (53%–65%)	1.63 (1.35–1.98)	0.56 (0.43–0.74)	44% (37%–51%)	79% (73%–85%)	21% (17%–25%)
FPR	93% (89%–98%)	19% (14%–24%)	1.16 (1.07–1.25)	0.34 (0.17–0.70)	36% (30%–41%)	86% (77%–95%)	14% (11%–18%)
ADAPT	100% (100%–100%)	3% (1%–5%)	1.03 (1.01–1.05)	0.00 (0.00–0.00)	33% (28%–38%)	100% (100%–100%)	0% (0%–1%)

Note: All stated as percentages with 95% CI in parentheses.

Abbreviations: ADAPT, Accelerated Diagnostic Protocol to Assess Patients with Chest Pain Symptoms Using Contemporary Troponins; EDACS, Emergency Department Assessment of Chest Pain Score; HEART, History, ECG, Age, Risk Factors, and Troponin; FPR, Florence Prediction Rule; GRACE, Global Registry of Acute Coronary Events; LR+, positive likelihood ratio; LR−, negative likelihood ratio; m.TIMI, modified TIMI; NACPR, The North American Chest Pain Rule; NPV, negative predictive value; PPV, positive predictive value; PURSUIT, Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy; TIMI, Thrombolysis in Myocardial Infarction.

Figure 1 ROC curves for risk scores.

Abbreviations: ADAPT, Accelerated Diagnostic Protocol to Assess Patients with Chest Pain Symptoms Using Contemporary Troponins; EDACS, Emergency Department Assessment of Chest Pain Score; HEART, History, ECG, Age, Risk Factors, and Troponin; FPR, Florence Prediction Rule; GRACE, Global Registry of Acute Coronary Events; m.TIMI, modified TIMI; NACPR, The North American Chest Pain Rule; PURSUIT, Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy; ROC, receiver–operator characteristic; TIMI, Thrombolysis in Myocardial Infarction.

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