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Meier M, Boeddinghaus J, Nestelberger T, Koechlin L, Lopez-Ayala P, Wussler D, Walter JE, Zimmermann T, Badertscher P, Wildi K, Giménez MR, Puelacher C, Glarner N, Magni J, Miró Ò, Martin-Sanchez FJ, Kawecki D, Keller DI, Gualandro DM, Twerenbold R, Nickel CH, Bingisser R, Mueller C. Comparing the utility of clinical risk scores and integrated clinical judgement in patients with suspected acute coronary syndrome. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:693-702. [PMID: 37435949 PMCID: PMC10599640 DOI: 10.1093/ehjacc/zuad081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 06/05/2023] [Accepted: 07/10/2023] [Indexed: 07/13/2023]
Abstract
AIMS The utility of clinical risk scores regarding the prediction of major adverse cardiac events (MACE) is uncertain. We aimed to directly compare the prognostic performance of five established clinical risk scores as well as an unstructured integrated clinical judgement (ICJ) of the treating emergency department (ED) physician. METHODS AND RESULTS Thirty-day MACE including all-cause death, life-threatening arrhythmia, cardiogenic shock, acute myocardial infarction (including the index event), and unstable angina requiring urgent coronary revascularization were centrally adjudicated by two independent cardiologists in patients presenting to the ED with acute chest discomfort in an international multicentre study. We compared the prognostic performance of the HEART score, GRACE score, T-MACS, TIMI score, and EDACS, as well as the unstructured ICJ of the treating ED physician (visual analogue scale to estimate the probability of acute coronary syndrome, ranging from 0 to 100). Among 4551 eligible patients, 1110/4551 patients (24.4%) had at least one MACE within 30 days. Prognostic accuracy was high and comparable for the HEART score, GRACE score, T-MACS, and ICJ [area under the receiver operating characteristic curve (AUC) 0.85-0.87] but significantly lower and only moderate for the TIMI score (AUC 0.79, P < 0.001) and EDACS (AUC 0.74, P < 0.001), resulting in sensitivities for the rule-out of 30-day MACE of 93-96, 87 (P < 0.001), and 72% (P < 0.001), respectively. CONCLUSION The HEART score, GRACE score, T-MACS, and unstructured ICJ of the treating physician, not the TIMI score or EDACS, performed well for the prediction of 30-day MACE and may be considered for routine clinical use. TRIAL REGISTRATION ClinicalTrials.gov number NCT00470587.
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Affiliation(s)
- Mario Meier
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Luca Koechlin
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Department of Cardiac Surgery, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Pedro Lopez-Ayala
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Desiree Wussler
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Department of Intensive Care Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Joan Elias Walter
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Emergency Department, Triemli Hospital, Zurich, Switzerland
| | - Tobias Zimmermann
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Department of Intensive Care Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane, Australia
| | - Maria Rubini Giménez
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Department of Cardiology and internal Medicine, University Heart Center Leipzig, Leipzig, Germany
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Noemi Glarner
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Jan Magni
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
| | - Òscar Miró
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Emergency Department, Hospital Clinic, Barcelona, Catalonia, Spain
| | | | - Damian Kawecki
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- 2nd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Katowice, Zabrze, Poland
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Zurich, Switzerland
| | - Danielle M Gualandro
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- University Center of Cardiovascular Science & Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian H Nickel
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Roland Bingisser
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and University Heart Center, University Hospital Basel, University of Basel, Petersgraben 4, Basel CH-4031, Switzerland
- GREAT Network, Via Antonio Serra 54, 00191 Rome, Italy
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Hasselbalch RB, Schultz M, Schytz PA, Kristensen JH, Strandkjær N, Pries-Heje M, Carlson N, Schou M, Bundgaard H, Torp-Pedersen C, Iversen KK. Predictive and prognostic value of different cardiac troponin assays: a nationwide register-based cohort study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2023; 9:592-599. [PMID: 36264293 DOI: 10.1093/ehjqcco/qcac065] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/03/2022] [Accepted: 10/17/2022] [Indexed: 09/13/2023]
Abstract
AIMS Guidelines do not differentiate between the available assays of cardiac troponin (cTn). We compared the prognostic and predictive ability of cTn assays. METHODS AND RESULTS This was a nationwide cohort study of patients with acute coronary syndrome (ACS) and ≥ 2 cTn measurements of one of four assays: Roche high-sensitivity cTnT (hs-cTnT), Abbott high sensitivity cTnI (hs-cTnI), Siemens Vista cTnI, and Siemens cTnI Ultra. Data were collected from Danish registries from 2009-18. Peak cTn concentration normalized to the 99th percentile was used. Outcomes were myocardial infarction (MI) during admission, one-year all-cause-, cardiovascular-, and non-cardiovascular mortality. Receiver operating characteristics and logistic regression calculating odds ratios (OR) were used. A total of 90 705 patients were included, of which 20 550 (23%) had MI. Siemens Vista cTnI was the strongest predictor of MI, Area under the curve (auc) 0.93 (95% CI 0.93-0.93). In 1 year 9012 (9.9%) of patients had died. An inverted U-shape relationship was observed between concentration of cTn and all-cause mortality. Hs-cTnT OR 21.3 (95% CI 18.4-24.8) at 2-5 times the 99th percentile and 12.1 (95% CI 10.3-14.1) for concentrations >100 times the 99th percentile. The inverted U-shape relationship was only present for non-cardiovascular mortality. The strongest predictor of cardiovascular mortality was hs-cTnT, OR 11.3 (95% CI 6.4-21.8) at 1-2 times the 99th percentile and 88.8 (95% CI 53.2-163.0) for concentrations >100 times the 99th percentile. CONCLUSION Siemens Vista cTnI was the strongest predictor of MI and hs-cTnT was the strongest predictor of mortality. An inverted U-shape relationship was observed between cTn concentration and non-cardiovascular mortality.
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Affiliation(s)
- Rasmus B Hasselbalch
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
| | - Martin Schultz
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
| | - Philip A Schytz
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
| | - Jonas H Kristensen
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
| | - Nina Strandkjær
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
| | - Mia Pries-Heje
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen 2100, Denmark
| | - Nicholas Carlson
- Department of Nephrology, Copenhagen University Hospital, Rigshospitalet, Copenhagen 2100, Denmark
- The Danish Heart Foundation, Copenhagen 1120, Denmark
| | - Morten Schou
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen 2200, Denmark
| | - Henning Bundgaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen 2100, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen 2200, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Nordsjaellands Hospital, Hilleroed 3400, Denmark
- Department of Public Health, University of Copenhagen, Copenhagen 2200, Denmark
| | - Kasper K Iversen
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital, Herlev and Gentofte Hospital, Copenhagen 2730, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen 2200, Denmark
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