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Kavsak PA, Cerasuolo JO, Ko DT, Ma J, Sherbino J, Mondoux SE, Clayton N, Hill SA, McQueen M, Griffith LE, Mehta SR, Perez R, Seow H, Devereaux PJ, Worster A. Using the clinical chemistry score in the emergency department to detect adverse cardiac events: a diagnostic accuracy study. CMAJ Open 2020; 8:E676-E684. [PMID: 33139388 PMCID: PMC7608943 DOI: 10.9778/cmajo.20200047] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The ability to rule out or in a major adverse cardiac event (MACE) in patients with suspected acute coronary syndrome at emergency department (ED) presentation would be beneficial to patient care and the health care system. The clinical chemistry score (CCS) was evaluated in this context. METHODS This diagnostic accuracy study evaluated 2 different ED cohorts with suspected acute coronary syndrome. For patients in cohort 1, who presented to the ED of 3 hospitals in Hamilton, Ontario, between May and August 2013, retrospective measurements were taken using the Ortho Clinical Diagnostics high-sensitivity cardiac troponin I (hs-cTnI) assay; for patients in cohort 2, who presented to the ED of the same 3 hospitals in Hamilton between November 2012 and February 2013, an ED cardiac presentation blood test panel was performed with the Abbott Diagnostics hs-cTnI assay. The sensitivity and specificity of the CCS (cut-offs of ≥ 1 and 5) and hs-cTnI alone (published cut-offs) were compared for MACE (composite of death, myocardial infarction, unstable angina, revascularization) at 30 days for both cohorts and at 90 days for cohort 2. RESULTS The incidence of MACE at 30 days was higher in cohort 1 (n = 1058) (19.4%, 95% confidence interval [CI] 16.8%-22.2%) than in cohort 2 (n = 5974) (14.6%, 95% CI 13.6%-15.6%). In cohort 1, a CCS of 1 or above yielded a sensitivity of 99.5% (95% CI 97.3%-99.9%). The sensitivity with an Ortho hs-cTnI cut-off of 1 ng/L or above was 91.2% (95% CI 86.5%-95.7%). The specificity of a CCS of 5 (97.8%, 95% CI 96.5%-98.7%) was higher than when the overall 99th-percentile cut-off for the Ortho hs-cTnI assay (> 11 ng/L; 90.1%, 95% CI 87.9%-92.0%) was used. A similar pattern was observed in cohort 2 at 30 days and persisted at 90 days with the Abbott hs-cTnI assay. INTERPRETATION The CCS derived with 2 different hs-cTnI assays and ED populations yielded higher sensitivity and specificity estimates for MACE than hs-cTnI alone. An intervention study is needed to evaluate the impact of the CCS at both the patient and hospital levels. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT01994577.
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Affiliation(s)
- Peter A Kavsak
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont.
| | - Joshua O Cerasuolo
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Dennis T Ko
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Jinhui Ma
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Jonathan Sherbino
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Shawn E Mondoux
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Natasha Clayton
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Stephen A Hill
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Matthew McQueen
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Lauren E Griffith
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Shamir R Mehta
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Richard Perez
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Hsien Seow
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - P J Devereaux
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
| | - Andrew Worster
- Department of Pathology and Molecular Medicine (Kavsak, Hill, McQueen), McMaster University; ICES McMaster (Cerasuolo, Perez, Seow), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES (Ko), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Ma, Griffith); Division of Emergency Medicine (Sherbino, Mondoux, Worster); Department of Medicine (Clayton); Division of Cardiology, and Population Health Research Institute (Mehta, Devereaux), McMaster University, Hamilton, Ont
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Kavsak PA, Cerasuolo JO, Mondoux SE, Sherbino J, Ma J, Hoard BK, Perez R, Seow H, Ko DT, Worster A. Risk Stratification for Patients with Chest Pain Discharged Home from the Emergency Department. J Clin Med 2020; 9:E2948. [PMID: 32932598 PMCID: PMC7565964 DOI: 10.3390/jcm9092948] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/10/2020] [Accepted: 09/10/2020] [Indexed: 12/17/2022] Open
Abstract
For patients with chest pain who are deemed clinically to be low risk and discharged home from the emergency department (ED), it is unclear whether further laboratory tests can improve risk stratification. Here, we investigated the utility of a clinical chemistry score (CCS), which comprises plasma glucose, the estimated glomerular filtration rate, and high-sensitivity cardiac troponin (I or T) to generate a common score for risk stratification. In a cohort of 14,676 chest pain patients in the province of Ontario, Canada and who were discharged home from the ED (November 2012-February 2013 and April 2013-September 2015) we evaluated the CCS as a risk stratification tool for all-cause mortality, plus hospitalization for myocardial infarction or unstable angina (primary outcome) at 30, 90, and 365 days post-discharge using Cox proportional hazard models. At 30 days the primary outcome occurred in 0.3% of patients with a CCS < 2 (n = 6404), 0.9% of patients with a CCS = 2 (n = 4336), and 2.3% of patients with a CCS > 2 (n = 3936) (p < 0.001). At 90 days, patients with CCS < 2 (median age = 52y (IQR = 46-60), 59.4% female) had an adjusted HR = 0.51 (95% confidence interval (CI) = 0.32-0.82) for the composite outcome and patients with a CCS > 2 (median age = 74y (IQR = 64-82), 48.0% female) had an adjusted HR = 2.80 (95%CI = 1.98-3.97). At 365 days, 1.3%, 3.4%, and 11.1% of patients with a CCS < 2, 2, or >2 respectively, had the composite outcome (p < 0.001). In conclusion, the CCS can risk stratify chest pain patients discharged home from the ED and identifies both low- and high-risk patients who may warrant different medical care.
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Affiliation(s)
- Peter A. Kavsak
- Department of Pathology and Molecular Medicine, McMaster University and Juravinski Hospital and Cancer Centre, 711 Concession Street Hamilton, Hamilton, ON L8V 1C3, Canada
| | - Joshua O. Cerasuolo
- ICES McMaster, Faculty of Health Sciences, McMaster University, Hamilton, ON L8S 4K1, Canada; (J.O.C.); (R.P.); (H.S.)
| | - Shawn E. Mondoux
- Division of Emergency Medicine, McMaster University, Hamilton, ON L8N 3Z5, Canada; (S.E.M.); (J.S.); (A.W.)
| | - Jonathan Sherbino
- Division of Emergency Medicine, McMaster University, Hamilton, ON L8N 3Z5, Canada; (S.E.M.); (J.S.); (A.W.)
| | - Jinhui Ma
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON L8N 3Z5, Canada;
| | | | - Richard Perez
- ICES McMaster, Faculty of Health Sciences, McMaster University, Hamilton, ON L8S 4K1, Canada; (J.O.C.); (R.P.); (H.S.)
| | - Hsien Seow
- ICES McMaster, Faculty of Health Sciences, McMaster University, Hamilton, ON L8S 4K1, Canada; (J.O.C.); (R.P.); (H.S.)
| | | | - Andrew Worster
- Division of Emergency Medicine, McMaster University, Hamilton, ON L8N 3Z5, Canada; (S.E.M.); (J.S.); (A.W.)
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Kavsak PA, Cerasuolo JO, Ko DT, Ma J, Sherbino J, Mondoux SE, Perez R, Seow H, Worster A. High-Sensitivity Cardiac Troponin I vs a Clinical Chemistry Score for Predicting All-Cause Mortality in an Emergency Department Population. CJC Open 2020; 2:296-302. [PMID: 32695979 PMCID: PMC7365813 DOI: 10.1016/j.cjco.2020.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 03/04/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND For patients investigated for suspected acute coronary syndrome, there is uncertainty if a single measurement of high-sensitivity cardiac troponin I (hs-cTnI) at emergency department (ED) presentation can identify patients at both low and high risk for mortality. METHODS We included consecutive adult patients in the ED who had a Clinical Chemistry Score (CCS) taken at presentation (ie, combination of glucose, creatinine for estimated glomerular filtration rate determination, and hs-cTnI assay) in a Canadian city between 2012 and 2013. Outcomes were 3-month, 1-year, and 5-year all-cause mortality using the provincial death registry. Mortality rates and test performance (eg, sensitivity and specificity) with 95% confidence intervals (CIs) were obtained for the CCS or hs-cTnI assay alone using established cutoffs for these tests. RESULTS Our cohort included 5974 patients with a 1-year mortality rate of 17.2% (95% CI, 16.2-18.3). A CCS ≥ 1 yielded a sensitivity of 99.2% (95% CI, 98.4-99.6) compared with the hs-cTnI ≥ 5 ng/L cutoff sensitivity of 88.4% (95% CI, 86.3-90.3), with the mortality rate being significantly lower for patients with CCS < 1 (2.0%; 95% CI, 0.9-4.0) vs patients with hs-cTnI < 5 ng/L (5.0%; 95% CI, 4.2-6.0) at 1 year (P = 0.01). A CCS of 5 also yielded a higher specificity (88.5%; 95% CI, 87.5-89.3) compared with hs-cTnI > 26 ng/L (83.9%; 95% CI, 82.9-84.9), with no difference in mortality rates (37.4% vs 36.3%; P = 0.66). This trend was consistent at 3-month and 5-year mortality. CONCLUSION For patients in the ED with a potential cardiac issue, using the CCS cutoffs can better identify patients at low and high risk for mortality than using published cutoffs for hs-cTnI alone.
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Affiliation(s)
- Peter A. Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Joshua O. Cerasuolo
- ICES McMaster, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Jinhui Ma
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Jonathan Sherbino
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Shawn E. Mondoux
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Richard Perez
- ICES McMaster, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Hsien Seow
- ICES McMaster, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Andrew Worster
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
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