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Ding WY, Romero-Aniorte AI, Tello-Montoliu A, Gil-Pérez P, López-García C, Veliz-Martínez A, Quintana-Giner M, Lip GYH, Rivera-Caravaca JM, Marín F. Simplified Geleijnse score for identifying chest pain features associated with coronary ischemia. Heart Lung 2023; 59:61-66. [PMID: 36739642 DOI: 10.1016/j.hrtlng.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 01/19/2023] [Accepted: 01/19/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND The Geleijnse score, which was proposed to assess for coronary ischemia, has practical limitations. OBJECTIVES Our aim was to design and evaluate a simplified version of the Geleijnse score. METHODS We enrolled patients with suspected coronary heart disease but negative troponin T or absence of enzymatic curve, and a non-diagnostic 12-lead ECG. The initial study was performed in a retrospective derivation cohort and the results were subsequently validated in a prospective cohort. RESULTS From 109 patients included in the derivation cohort, 33 (30.3%) received a diagnosis of coronary heart disease. Chest pain with both arms radiation (OR 3.54), severe intensity (OR 2.41), improvement by nitroglycerin (OR 1.61), associated dyspnea (OR 1.97) and prior exertional angina history (OR 2.91) were independently associated with an ischemic origin on multivariate logistic regression analysis. ROC curves comparison demonstrated both the original and simplified scores presented modest predictive ability with significant difference when analyzed using dichotomous cut-offs (0.647 [simplified] vs. 0.544 [original], p = 0.042) but not as a continuous variable (0.670 [simplified] vs. 0.621 [original], p = 0.396). In 305 patients from the validation cohort, the simplified score presented extensively increased predictive accuracy than the Geleijnse, in the continuous (c-indexes = 0.735 vs. 0.685, p = 0.040) and the dichotomic (c-indexes = 0.682 vs. 0.514, p<0.001) forms. CONCLUSIONS A simplified version of the Geleijnse score, including some routine clinical manifestations associated with coronary heart disease, presented significantly better predictive ability compared to the original score.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Ana Isabel Romero-Aniorte
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Antonio Tello-Montoliu
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Pablo Gil-Pérez
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Cecilia López-García
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Andrea Veliz-Martínez
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Miriam Quintana-Giner
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - José Miguel Rivera-Caravaca
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain; Faculty of Nursing, University of Murcia, Murcia, Spain.
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
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Cakir C, Ceylan Y, Akbal OY, Sarikaya R, Barutcu S. Clinical characteristics and angiographic findings of non-ST-elevation acute coronary syndrome patients admitted with normal electrocardiogram. J Electrocardiol 2020; 60:77-81. [PMID: 32305725 DOI: 10.1016/j.jelectrocard.2020.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 02/24/2020] [Accepted: 03/07/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Cayan Cakir
- University of Health Sciences Van Training and Research Hospital, Van, Turkey.
| | | | - Ozgur Yasar Akbal
- University of Health Sciences Kartal Kosuyolu High Specialization Training and Research Hospital, Kartal, Istanbul, Turkey
| | - Remzi Sarikaya
- University of Health Sciences Van Training and Research Hospital, Van, Turkey
| | - Suleyman Barutcu
- University of Health Sciences Van Training and Research Hospital, Van, Turkey
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Sanchis J, Bodí V, Núñez J, Núñez E, Bosch X, Pellicer M, Heras M, Bardají A, Marrugat J, Llácer A. Identification of very low risk chest pain using clinical data in the emergency department. Int J Cardiol 2011; 150:260-3. [DOI: 10.1016/j.ijcard.2010.04.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Revised: 01/25/2010] [Accepted: 04/03/2010] [Indexed: 11/30/2022]
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Martínez-Sellés M, Datino T, Estévez A, Fernández Avilés F. Chest pain with an elevated troponin level but without significant coronary artery disease is not usually due to an infarction. Rev Esp Cardiol 2010; 63:371-373. [PMID: 20197005 DOI: 10.1016/s1885-5857(10)70077-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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Martínez-Sellés M, Datino T, Estévez Á, Fernández Avilés F. Dolor torácico con elevación de troponina y coronarias sin lesiones significativas no suele ser infarto. Rev Esp Cardiol (Engl Ed) 2010. [DOI: 10.1016/s0300-8932(10)70103-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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6
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Respuesta. Rev Esp Cardiol (Engl Ed) 2010; 63:372-3. [DOI: 10.1016/s0300-8932(10)70104-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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7
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Martínez-Sellés M, Bueno H, Estévez Á, De Miguel J, Muñoz J, Fernández-Avilés F. Positive non-invasive tests in the chest pain unit: importance of the clinical profile for estimating the probability of coronary artery disease. ACTA ACUST UNITED AC 2009; 10:205-8. [DOI: 10.1080/17482940701805408] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Martínez-Sellés M, Bueno H, Estévez Á, Fernández-Avilés F. Respuesta. Rev Esp Cardiol (Engl Ed) 2009; 62:228. [DOI: 10.1016/s0300-8932(09)70170-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Martínez-Sellés M, Bueno H, Sacristán A, Estévez Á, Ortiz J, Gallegoa L, Fernández-Avilés F. Dolor torácico en urgencias: frecuencia, perfil clínico y estratificación de riesgo. Rev Esp Cardiol 2008. [DOI: 10.1157/13125517] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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10
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Sanchis J, Bodí V, Núñez J, Bosch X, Loma-Osorio P, Mainar L, Santas E, Miñana G, Robles R, Llàcer A. Limitations of clinical history for evaluation of patients with acute chest pain, non-diagnostic electrocardiogram, and normal troponin. Am J Cardiol 2008; 101:613-7. [PMID: 18308008 DOI: 10.1016/j.amjcard.2007.10.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2007] [Revised: 10/02/2007] [Accepted: 10/02/2007] [Indexed: 12/22/2022]
Abstract
Decision making and risk stratification for patients with acute chest pain, nondiagnostic electrocardiogram results, and normal troponin levels are challenging. The aim of this study was to optimize the clinical history for the evaluation of these patients. A total of 1,011 patients presenting to an emergency department were included. The following data were collected: clinical presentation (pain characteristics and number of pain episodes), coronary risk factors, previous ischemic heart disease, and extracardiac vascular disease (peripheral artery disease, stroke, or creatinine >1.4 mg/dl). Two different predictive models were calculated according to the end points: model 1 for 1-year major events (death or myocardial infarction) and model 2 for 30-day cardiac events (major events or revascularization). For 1-year major events, model 1 showed optimal discrimination capacity (C statistic = 0.80), which was significantly better than that of model 2 (C statistic = 0.77, p = 0.04). With respect to 30-day cardiac events, however, discrimination was lower in the 2 models, without differences between them (C statistic = 0.74 vs 0.75, p = NS). Using model 1, a large low-risk subgroup with <3 predictive variables could be defined, including 442 patients (44% of the total population) with a 1.4% rate of 1-year major events; however, the incidence of 30-day cardiac events (8%) was not negligible, mainly because of revascularizations. In conclusion, in patients with acute chest pain of uncertain coronary origin, clinical predictive models afford good risk stratification for long-term major events. Short-term outcomes, including revascularization, however, are not predicted as well. Therefore, ancillary tools, such as noninvasive stress tests, should be implemented for decision making at initial hospitalization or discharge.
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Affiliation(s)
- Juan Sanchis
- Servei de Cardiologia, Hospital Clínic Universitari, Universitat de València, València, Spain.
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Hess EP, Wells GA, Jaffe A, Stiell IG. A study to derive a clinical decision rule for triage of emergency department patients with chest pain: design and methodology. BMC Emerg Med 2008; 8:3. [PMID: 18254973 PMCID: PMC2275746 DOI: 10.1186/1471-227x-8-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Accepted: 02/06/2008] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Chest pain is the second most common chief complaint in North American emergency departments. Data from the U.S. suggest that 2.1% of patients with acute myocardial infarction and 2.3% of patients with unstable angina are misdiagnosed, with slightly higher rates reported in a recent Canadian study (4.6% and 6.4%, respectively). Information obtained from the history, 12-lead ECG, and a single set of cardiac enzymes is unable to identify patients who are safe for early discharge with sufficient sensitivity. The 2007 ACC/AHA guidelines for UA/NSTEMI do not identify patients at low risk for adverse cardiac events who can be safely discharged without provocative testing. As a result large numbers of low risk patients are triaged to chest pain observation units and undergo provocative testing, at significant cost to the healthcare system. Clinical decision rules use clinical findings (history, physical exam, test results) to suggest a diagnostic or therapeutic course of action. Currently no methodologically robust clinical decision rule identifies patients safe for early discharge. METHODS/DESIGN The goal of this study is to derive a clinical decision rule which will allow emergency physicians to accurately identify patients with chest pain who are safe for early discharge. The study will utilize a prospective cohort design. Standardized clinical variables will be collected on all patients at least 25 years of age complaining of chest pain prior to provocative testing. Variables strongly associated with the composite outcome acute myocardial infarction, revascularization, or death will be further analyzed with multivariable analysis to derive the clinical rule. Specific aims are to: i) apply standardized clinical assessments to patients with chest pain, incorporating results of early cardiac testing; ii) determine the inter-observer reliability of the clinical information; iii) determine the statistical association between the clinical findings and the composite outcome; and iv) use multivariable analysis to derive a highly sensitive clinical decision rule to guide triage decisions. DISCUSSION The study will derive a highly sensitive clinical decision rule to identify low risk patients safe for early discharge. This will improve patient care, lower healthcare costs, and enhance flow in our busy and overcrowded emergency departments.
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Affiliation(s)
- Erik P Hess
- Department of Emergency Medicine, University of Ottawa, Ottawa, Canada
| | - George A Wells
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
| | - Allan Jaffe
- Department of Internal Medicine, Division of Cardiology, Mayo Clinic College of Medicine, Rochester, USA
| | - Ian G Stiell
- Department of Emergency Medicine, Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
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Martínez-Sellés M, Bueno H, Sacristán A, Estévez Á, Ortiz J, Gallego L, Fernández-Avilés F. Chest Pain in the Emergency Department: Incidence, Clinical Characteristics, and Risk Stratification. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/s1885-5857(08)60256-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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13
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Candell-Riera J, Oller-Martínez G, de León G, Castell-Conesa J, Aguadé-Bruix S. Yield of early rest and stress myocardial perfusion single-photon emission computed tomography and electrocardiographic exercise test in patients with atypical chest pain, nondiagnostic electrocardiogram, and negative biochemical markers in the emergency department. Am J Cardiol 2007; 99:1662-6. [PMID: 17560871 DOI: 10.1016/j.amjcard.2007.01.048] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2006] [Revised: 01/17/2007] [Accepted: 01/17/2007] [Indexed: 11/30/2022]
Abstract
There are no studies in which diagnostic yield of early rest myocardial perfusion gated single-photon emission computed tomography (SPECT), electrocardiographic exercise testing, and stress SPECT were compared in patients with atypical chest pain, nondiagnostic electrocardiograms (ECGs), and negative markers of myocardial damage in the emergency department. A prospective study of 96 patients who presented with atypical chest pain and nondiagnostic ECG, but without elevated markers of necrosis, was performed. All underwent rest gated SPECT using technetium-99m methoxyisobutyl isonitrile within 6 hours after pain subsided followed by an electrocardiographic exercise test to obtain stress-rest SPECT images. After 1 year, there were no deaths and coronary artery disease was confirmed in only 5 patients. Negative predictive values of the 3 techniques were high (99%, 96%, and 100%, respectively), but positive predictive values were low (27%, 22%, and 14%, respectively). Sensitivities of early SPECT (80%) and stress SPECT (100%) were higher than for the electrocardiographic exercise test (40%). In conclusion, in patients with atypical chest pain, nondiagnostic ECG, and negative biochemical markers, negative predictive values of the 3 tests analyzed are very high. The sensitivity of radionuclide tests is higher, but their widespread use does not appear warranted because their positive predictive value and incidence of complications is low.
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Affiliation(s)
- Jaume Candell-Riera
- Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
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Castillo Moreno JA, Ramos Martín JL, Molina Laborda E, Egea Beneyto S, Ortega Bernal J. Utilidad del perfil clínico y la ergometría en la valoración del pronóstico de los pacientes ingresados por dolor torácico sin criterios de alto riesgo. Rev Esp Cardiol 2006. [DOI: 10.1157/13083644] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Sanz G. Estratificación del riesgo en la unidad de dolor torácico: un problema no resuelto. Rev Esp Cardiol (Engl Ed) 2005. [DOI: 10.1157/13077227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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