Use of a simple clinical score to predict prognosis of patients with normal or mildly abnormal resting electrocardiographic findings undergoing evaluation for coronary artery disease

Nonspecific electrocardiographic abnormalities are associated with increased length of stay and adverse cardiac outcomes in prehospital chest pain

BACKGROUND

Nonspecific ST-T repolarization (NST) abnormalities alter the ST-segment for reasons often unrelated to acute myocardial ischemia, which could contribute to misdiagnosis or inappropriate treatment. We sought to define the prevalence of NST patterns in patients with chest pain and evaluate how such patterns correlate with the eventual etiology of chest pain and course of hospitalization.

METHODS

This was a prospective observational study that included consecutive prehospital chest pain patients from three tertiary care hospitals in the U.S. Two independent reviewers blinded from clinical data audited the prehospital 12-lead ECG for the presence or absence of NST patterns (i.e., right or left bundle branch block, left ventricular hypertrophy with strain pattern, ventricular pacing, ventricular rhythm, or coarse atrial fibrillation). The primary outcome was 30-day major adverse cardiac events (MACE) defined as cardiac arrest, acute heart failure, post-discharge infarction, or all-cause death.

RESULTS

The final sample included 750 patients (age 59 ± 17, 58% males). A total of 40 patients (5.3%) experienced 30-MACE and 131 (17.5%) had NST patterns. The presence of NST patterns was an independent multivariate predictor of 30-day MACE (9.9% vs. 4.4%, OR = 2.2 [95% CI = 1.1-4.5]. Patients with NST patterns had increased median length of stay (1.0 [IQR 0.5-3] vs. 2.0 [IQR 1-4] days, p < 0.05) independent of the etiology of chest pain.

CONCLUSIONS

One in six prehospital ECGs of patients with chest pain has NST patterns. This pattern is associated with increased length of stay and adverse cardiac outcomes, suggesting the need of preventive measures and close follow up in such patients.

Age- and sex-based resource utilisation and costs in patients with acute chest pain undergoing cardiac CT angiography: pooled evidence from ROMICAT II and ACRIN-PA trials

OBJECTIVES

To determine resource utilisation according to age and gender-specific subgroups in two large randomized diagnostic trials.

METHODS

We pooled patient-specific data from ACRIN-PA 4005 and ROMICAT II that enrolled subjects with acute chest pain at 14 US sites. Subjects were randomized between a standard work-up and a pathway utilizing cardiac computed tomography angiography (CCTA) and followed for the occurrence of acute coronary syndrome (ACS) and resource utilisation during index hospitalisation and 1-month follow-up. Study endpoints included diagnostic accuracy of CCTA for the detection of ACS as well as resource utilisation.

RESULTS

Among 1240 patients who underwent CCTA, negative predictive value of CCTA to rule out ACS remained very high (≥99.4%). The proportion of patients undergoing additional diagnostic testing and cost increased with age for both sexes (p < 0.001), and was higher in men as compared to women older than 60 years (43.1% vs. 23.4% and $4559 ± 3382 vs. $3179 ± 2562, p < 0.01; respectively). Cost to rule out ACS was higher in men (p < 0.001) and significantly higher for patients older than 60 years ($2860-5935 in men, p < 0.001).

CONCLUSIONS

CCTA strategy in patients with acute chest pain results in varying resource utilisation according to age and gender-specific subgroups, mandating improved selection for advanced imaging.

KEY POINTS

• In this analysis, CAD and ACS increased with age and male gender. • CCTA in patients with acute chest pain results in varying resource utilisation. • Significant increase of diagnostic testing and cost with age for both sexes. • Cost to rule out ACS is higher in men and patients >60 years. • Improved selection of subjects for cardiac CTA result in more resource-driven implementation.

Risk stratification in chest pain patients undergoing nuclear stress testing: the Erlanger Stress Score

BACKGROUND

Studies have individually reported the relationship of age, cardiac risk factors, and history of preexisting coronary artery disease (CAD) for predicting acute coronary syndromes in chest pain patients undergoing cardiac stress testing. In this study, we investigate the interplay of all these factors on the incidence of acute coronary syndromes to develop a tool that may assist physicians in the selection of appropriate chest pain patients for stress testing.

METHODS

Retrospective analysis of a prospectively acquired database of consecutive chest pain patients undergoing nuclear stress testing. Backward stepwise logistic regression was used to develop a model for predicting risk of 30-day acute coronary events (ACE) using information obtained from age, sex, cardiac risk factors, and history of preexisting CAD.

RESULTS

A total of 800 chest pain patients underwent nuclear stress testing. ACE occurred in 74 patients (9.3%). Logistic regression analysis found only 6 factors predictive of ACE: age, male sex, preexisting CAD, diabetes, and hyperlipidemia. Area under the receiver operator characteristic curve of this model for predicting ACE was 0.767 (95% confidence interval, 0.719-0.815). There were no cases of ACE in the 173 patients with predicted probability estimates ≤2.5% (95% confidence interval, 0%-2.1%).

CONCLUSIONS

A regression model using age, sex, preexisting CAD, diabetes, and hyperlipidemia is predictive of 30-day ACE in chest pain patients undergoing nuclear stress testing. Prospective studies need to be performed to determine whether this model can assist physicians in the selection of appropriate low-to-intermediate risk chest pain patients for nuclear stress testing.

Improving risk stratification in patients with chest pain: the Erlanger HEARTS3 score

BACKGROUND

The HEART score uses elements from patient History, Electrocardiogram, Age, Risk Factors, and Troponin to obtain a risk score on a 0- to 10-point scale for predicting acute coronary syndromes (ACS). This investigation seeks to improve on the HEART score by proposing the HEARTS(3) score, which uses likelihood ratio analysis to give appropriate weight to the individual elements of the HEART score as well as incorporating 3 additional "S" variables: Sex, Serial 2-hour electrocardiogram, and Serial 2-hour delta troponin during the initial emergency department valuation.

METHODS

This is a retrospective analysis of a prospectively acquired database consisting of 2148 consecutive patients with non-ST-segment elevation chest pain. Interval analysis of likelihood ratios was performed to determine appropriate weighting of the individual elements of the HEART(3) score. Primary outcomes were 30-day ACS and myocardial infarction.

RESULTS

There were 315 patients with 30-day ACS and 1833 patients without ACS. Likelihood ratio analysis revealed significant discrepancies in weight of the 5 individual elements shared by the HEART and HEARTS(3) score. The HEARTS(3) score outperformed the HEART score as determined by comparison of areas under the receiver operating characteristic curve for myocardial infarction (0.958 vs 0.825; 95% confidence interval difference in areas, 0.105-0.161) and for 30-day ACS (0.901 vs 0.813; 95% confidence interval difference in areas, 0.064-0.110).

CONCLUSION

The HEARTS(3) score reliably risk stratifies patients with chest pain for 30-day ACS. Prospective studies need to be performed to determine if implementation of this score as a decision support tool can guide treatment and disposition decisions in the management of patients with chest pain.

The prevalence of the cardiac origin of chest pain: the experience of a rural area of southeast Italy

This study was designed to assess the application of diagnostic guidelines to the management of chest pain by an observational study carried out in a small town (Ragusa) of southeast Sicily. This study was an attempt to compare a Sicilian experience with the literature. In this observational study, we examined all the patients referred for chest pain to the Emergency Department (ED) of "Civile-M. P. Arezzo" Hospital during a period of 6 months (from January 1st 2008 to June 30th 2008). As much as 857 patients were studied. The results of our study show that musculoskeletal chest pain is the most common final diagnosis (49%), followed by cardiac chest pain (26.3%), gastrointestinal chest pain (13%), pulmonary chest pain (7%) and psychiatric chest pain (4%). The majority of patients (95%) never made contact with their primary care providers, and came straight to ED. These results emphasize the need for reworking a strategy to avoid the situation in which all cases of non-emergency chest pain, such as musculoskeletal ones, come to the hospital for evaluation, thereby overwhelming the ED, particularly in rural areas where the management of any emergency is centralized in a single hospital.

Usefulness of age and gender in the early triage of patients with acute chest pain having cardiac computed tomographic angiography

To identify the age- and gender-specific subpopulations of patients with acute chest pain in whom coronary computed tomographic angiography (CTA) will yield the greatest diagnostic benefit. Subjects with acute chest pain and an inconclusive initial evaluation (nondiagnostic electrocardiograhic findings, negative cardiac biomarkers) underwent contrast-enhanced 64-slice coronary CTA as a part of an observational cohort study. Independent investigators determined the presence of significant coronary stenosis (>50% luminal narrowing) and the occurrence of acute coronary syndrome (ACS) during the index hospitalization. We determined the diagnostic accuracy and effect on pretest probability of ACS using Bayes' theorem by age and gender. Of 368 patients (age 52.7 +/- 12 years, 61% men), 8% had ACS. The presence of significant coronary stenosis on CTA and the occurrence of ACS increased with age for both men and women (p <0.001). Cardiac CTA was highly sensitive and specific in women <65 years of age (sensitivity 100% and specificity >87%) and men <55 years of age (sensitivity 100% for men <45 years and 80% for men 45 to 54 years old; specificity >88.2%). Moreover, in these patients, coronary CTA led to restratification from low to high risk (for positive findings on CTA) or from low to very low risk (for negative findings on CTA). In contrast, a negative result on CTA did not result in restratification to a low-risk category in women >65 years and men >55 years old. In conclusion, the present analysis provides initial evidence that men <55 years and women <65 years might benefit more from cardiac CTA than older patients. Thus, age and gender might serve as simple criteria to appropriately select patients who would derive the greatest diagnostic benefit from coronary CTA in the setting of acute chest pain.

The Value of Myocardial Perfusion Single-Photon Emission Computed Tomography in Screening Asymptomatic Patients With Atrial Fibrillation for Coronary Artery Disease

OBJECTIVES

We sought to determine if screening for coronary artery disease (CAD) with stress single-photon emission computed tomography (SPECT) is of value in patients with atrial fibrillation (AF) who do not have symptoms of chest pain or dyspnea.

BACKGROUND

Although noninvasive stress testing is often done to screen for CAD in asymptomatic patients with AF and is considered to be appropriate in selected patients, its potential utility has not been demonstrated.

METHODS

A retrospective study was conducted of 374 asymptomatic patients with AF referred for the detection of CAD. Mean follow-up was 5.7 +/- 3.8 years. The study group was compared with a control group of 374 asymptomatic age and gender-matched patients without AF.

RESULTS

The mean summed stress score (SSS) was not significantly different between AF patients and control subjects (3.6 +/- 5.3 vs. 3.5 +/- 5.9; p = 0.35). Compared with controls, asymptomatic AF patients had similar rates of abnormal SPECT studies (51.6% vs. 48.4%; p = 0.38) and high-risk studies (14.4% vs. 14.4%; p = 1.0). The SSS was a significant predictor of outcome in both AF patients and control subjects. However, total mortality was significantly greater in AF patients (5-year overall mortality 27% vs. 18%, 10-year overall mortality 47% vs. 40%; p < 0.001), and this difference persisted (p = 0.01) after adjusting for multiple clinical variables and the SSS.

CONCLUSIONS

Screening for CAD using stress SPECT in asymptomatic AF patients has a yield similar to age- and gender-matched control patients without AF. Although SSS predicts mortality in patients with and without AF, patients with AF have increased total mortality independent of the findings on stress SPECT. These results suggest that factors other than obstructive CAD are responsible for the increased mortality in AF.

A pretest prognostic score to assess patients undergoing exercise or pharmacological stress testing

OBJECTIVE

A previously developed pretest score was validated to stratify patients presenting for exercise testing with suspected coronary disease according to the presence of angiographic coronary disease. Our goal was to determine how well this pretest score risk stratified patients undergoing pharmacological and exercise stress tests concerning prognostic endpoints.

DESIGN

Retrospective cohort analysis.

SETTING

University hospital stress laboratory.

PATIENTS

7452 unselected ambulatory patients with symptoms of suspected coronary disease undergoing stress testing between 1995 and 2004.

MAIN OUTCOMES MEASURES

All-cause death, cardiac death and non-fatal myocardial infarction.

RESULTS

The rate of all-cause death was 5.5% (CI 5.0 to 6.1) with 4.3 (SD 2.4) years of follow-up (Exercise 2.8% (CI 2.3 to 3.2) v Pharmacological group 11.9% (CI 10.5 to 13.3); p<0.001). The rate of cardiac death/myocardial infarction was 2.6% (CI 2.2 to 3.0) (Exercise 1.4% (CI 1.1 to 1.8) v Pharmacological group 5.3% (CI 4.3 to 6.2); p<0.001). In both groups, stratification by pretest score was significant for all-cause death and the combined endpoint. However, stratification was more effective in the pharmacological group using the combined endpoint rather than all-cause death. Pharmacological stress patients in intermediate and high risk groups were at higher risk than their respective exercise test cohorts. Referral for pharmacological stress testing was found to be an independent predictor of time to death (2.7 (CI 2.0 to 3.6); p<0.001).

CONCLUSION

A pretest score previously validated to stratify according to angiographic outcomes, effectively risk stratified pharmacological and exercise stress patients according to the combined endpoint of cardiac death/myocardial infarction.

Prognosis research: why is Dr. Lydgate still waiting?

BACKGROUND

Understanding prognosis--the future risk of adverse outcomes among people with existing disease--plays third fiddle behind clinical research into therapeutic interventions and novel diagnostic technologies.

METHODS AND RESULTS

Diseases show marked variations in a wide range of prognostic outcomes, yet these variations have seldom been the subject of systematic and sustained epidemiologic and multidisciplinary research. This is important to prioritize hypotheses for testing in intervention studies in groups, and to refine tools for prognostication in individuals. Methodologic standards for the design, conduct, analysis and reporting of prognosis research are required. Training is needed for the clinicians, policymakers, and payers who use prognostic information.

CONCLUSION

Here, arguments detracting from the potential scope of prognosis research are rebutted and misconceptions addressed with the aim of stimulating debate on the evolving role of prognosis research.

Headache response to glyceryl trinitrate in patients with and without obstructive coronary artery disease

OBJECTIVES

To examine the hypothesis that glyceryl trinitrate (GTN) may cause headache in patients with normal coronary arteries more often than in patients with obstructive coronary artery disease (CAD). This simple assessment may aid clinicians in the initial evaluation of chest pain syndrome and possible CAD.

PATIENTS AND METHODS

118 patients (66 men and 52 women) with new onset of chest pain were enrolled in this study. Patients were excluded from the study if they had a history of chronic headache, long term nitrates use, or any coronary artery procedures. Mean age of the patients was 62.5 years. Coronary angiography was performed within one month of GTN administration with the usual clinical indications such as recurrent chest pain, abnormal ECG, or abnormal results of stress tests. Thirty patients had normal coronary arteries or minimal or non-obstructive CAD. Eighty eight patients had obstructive CAD defined as luminal narrowing greater than 50% in any one or more of the left or right coronary arteries or their major branches. All the patients had a varying degree of relief of chest pain with GTN administration within 10 minutes. 36% of patients reported significant headache after GTN administration.

RESULTS

In patients with normal coronary arteries or minimal CAD, 73% had significant headache caused by sublingual GTN. In patients with obstructive CAD, only 23% had significant headache after GTN use (p < 0.001). There were no differences in patients' sex and vascular risk factors concerning the frequency of headache in patients with or without obstructive CAD.

CONCLUSIONS

GTN causes significantly more frequent headache episodes in patients with normal coronary arteries or minimal CAD than in patients with obstructive CAD. This unique finding may provide clinicians with an additional tool for the differential diagnosis of patients with chest pain syndrome.

A simple clinical score accurately predicts outcome in a community-based population undergoing stress testing

PURPOSE

Scoring systems based on clinical variables are available but not widely applied for evaluating patients with chronic coronary artery disease. The purpose of this study was to validate the prognostic value of a simple clinical scoring system, originally developed in patients referred for a nuclear stress test at a tertiary-care medical center, in a less-selected, community-based population undergoing stress testing for known or suspected coronary artery disease.

SUBJECTS AND METHODS

Over a 4-year period, 3546 residents of Olmsted County, Minn, underwent stress testing. A previously developed clinical score was calculated for every patient by assigning 1 point each for: male sex, history of myocardial infarction, typical angina, diabetes, insulin use, and each decade of age beginning at age 40. The associations between the assigned score and clinical endpoints were tested using logistic regression. A previously established cutoff point of 5 was used to establish risk groups.

RESULTS

During follow-up (7.6 +/- 2.7 years) there were 363 total deaths, 109 cardiac deaths, and 132 nonfatal myocardial infarctions. The clinical score was strongly associated with overall mortality, cardiac death, and cardiac death/myocardial infarction (P <0.001 for all 3 endpoints). Annual mortality was .6% for the 3076 patients (86%) with a score < or =4, 2.4% for 275 patients (8%) with a score = 5 and 6.2% for the 215 patients (6%) with a score > or =6.

CONCLUSIONS

This study enhances the generalizability of this simple clinical score, which was highly effective for risk-stratifying this community-based population undergoing evaluation of chronic coronary artery disease.

A prognostic score for prediction of cardiac mortality risk after adenosine stress myocardial perfusion scintigraphy

OBJECTIVES

We sought to derive and validate a score to estimate risk after adenosine stress.

BACKGROUND

Maximizing the prognostic information extracted from adenosine stress myocardial perfusion scintigraphy, a commonly performed test, is often challenging for referring physicians.

METHODS

A split-set validation of a score predicting cardiovascular mortality was performed in 5,873 consecutive patients studied by adenosine stress, dual-isotope single-photon emission computed tomography (SPECT; follow-up 94% complete, mean 2.2 +/- 1.1 years).

RESULTS

On follow-up, 387 cardiac deaths occurred (6.6%). The Cox proportional hazards model most predictive of cardiac death included age, % myocardium ischemic, % myocardium fixed, early revascularization, dyspnea, diabetes mellitus, rest and peak stress heart rates, abnormal rest electrocardiogram (ECG), and an interaction between % myocardium ischemic and early revascularization (chi-square = 376). The final prognostic score was calculated as follows: (age [decades] x 5.19) + (% myocardium ischemic [per 10%] x 4.66) + (% myocardium fixed [per 10%] x 4.81) + (diabetes mellitus x 3.88) + (if patient treated with early revascularization, 4.51) + (if dyspnea was a presenting symptom, 5.47) + (resting heart rate [per 10 beats] x 2.88) - (peak heart rate [per 10 beats] x 1.42) + (ECG score x 1.95) - (if patient treated with early revascularization, % myocardium ischemic [per 10%] x 4.47). Scores of <49, 49 to 57, and >57 identified low, intermediate, and high risk (0.9%, 3.3%, and 9.5% cardiac death/year, respectively). Score results further risk stratified patients with respect to cardiac death in all categories of SPECT abnormality.

CONCLUSIONS

We derived and validated a score incorporating data available after adenosine stress perfusion SPECT. This score maximizes the prognostic information extracted from this test and may enhance the application of this test as part of an overall strategy.

Comorbidity Assessment in Localized Prostate Cancer: A Review of Currently Available Techniques

Pathological nomograms have allowed urologists to make accurate predictions about the behaviour of localized prostate cancers. However, predicting overall outcome and survival is not solely dependent on tumour characteristics; comorbidity is also a vital determinant of outcome The majority of prostate cancers are diagnosed in men over 65 years of age and many will have significant competing comorbid disease that will need to be accounted when considering eligibility for radical treatment. Most urologists currently make an educated guess about the risk posed by comorbid disease. Such an approach has the potential to allow personal bias to influence what should be an objective measure. This review describes the available methods for objectively assessing comorbid risk and assesses their potential utility to men with localized prostate cancer being considered for radical treatment.

Utility of myocardial perfusion imaging in patients with low-risk treadmill scores

OBJECTIVES

The purpose of this study was to determine whether a previously validated clinical score (CS) could identify patients with a low-risk Duke treadmill score who had a higher risk of adverse events and, therefore, in whom myocardial perfusion imaging would be valuable for risk stratification.

BACKGROUND

Current American College of Cardiology/American Heart Association guidelines recommend using a standard exercise test without imaging as the initial test in patients who have an interpretable electrocardiogram and are able to exercise.

METHOD

We studied 1,461 symptomatic patients with low-risk Duke treadmill scores (> or =5) who underwent myocardial perfusion imaging. The CS was derived by assigning one point to each of the following variables: typical angina, history of myocardial infarction, diabetes, insulin use, male gender, and each decade of age over 40 years. A CS cutoff > or =5 or <5 was used to categorize patients as high risk (n = 303 [21%]) or low risk (n = 1,158 [79%]). Perfusion scans were categorized as low, intermediate, or high risk on the basis of the global stress score (GSS).

RESULTS

High-risk scans were more common in patients with a high-risk CS (26.4% vs. 9.5%, p < 0.0001). The CS and GSS were significant independent predictors of cardiac death. However, in patients with a low CS, seven-year cardiac survival was excellent, regardless of the GSS (99% for normal scans, 99% for mildly abnormal scans, and 99% for severely abnormal scans). In contrast, patients with a high CS had a lower seven-year survival rate (92%), which varied with GSS (94% for normal scans, 94% for mildly abnormal scans, and 84% for severely abnormal scans; p < 0.001).

CONCLUSIONS

In symptomatic patients with low-risk Duke treadmill scores and low clinical risk, myocardial perfusion imaging is of limited prognostic value. In patients with low-risk Duke treadmill scores and high clinical risk, annual cardiac mortality (>1%) is not low, and myocardial perfusion imaging has independent prognostic value.