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

Abstract

IntroductionWe compared performance of nine risk scores for coronary heart disease (CHD) among patients presenting to an emergency department (ED) with undifferentiated chest pain of possible coronary origin.MethodsA retrospective study was undertaken of adult patients presenting with chest pain to atertiary hospital ED with no electrocardiographs or troponin results diagnostic of ischemic chest pain (ICP) or acute coronary syndrome at ED presentation, and no clearly evident noncoronary diagnosis. Risk scores were applied using cut-points distinguishing low- from high-risk patients according to discharge diagnosis of noncardiac chest pain (NCCP) or ICP, respectively. A lower odds ratio (OR) for ICP denoted lower risk for ICP. Score performance was compared using area under receiver–operator characteristic curves (AUC) and predictive values.ResultsA total of 401 patients were studied, of whom 123 (30.7%) had ICP as final diagnosis. Among the nine risk scores, those with greatest ability to detect low-risk patients were The North American Chest Pain Rule (NACPR) score (OR=0.35, 95% CI=0.27–0.46); History, ECG, Age, Risk Factors, and Troponin (HEART) score (OR=0.43; 95% CI=0.35–0.52); and Thrombolysis in Myocardial Infarction (TIMI) score (OR=0.49; 95% CI=0.41–0.58). Discrimination between patients with NCCP and those with ICP was greatest for HEART score (AUC=0.82; 95% CI=0.78–0.86) and lowest for Accelerated Diagnostic Protocol to Assess Patients with Chest Pain Symptoms Using Contemporary Troponins (ADAPT) score (AUC=0.63; 95% CI=0.58–0.69). In excluding ICP, ADAPT had negative predictive value (NPV) 100% (miss rate 0%) but classified only 1.7% of patients as low risk, compared to NACPR with NPV 98% (miss rate 2%), classifying 10.2% as low risk, and HEART with NPV 94% (miss rate 6%), classifying 32.4% as low risk.ConclusionThe NACPR risk score maximized yield of low-risk patients with lowest miss rate for ICP, while HEART score classified highest proportion of low-risk patients but with a higher miss rate.