A clinical score to obviate the need for cardiac stress testing in patients with acute chest pain and negative troponins.
Am J Emerg Med 2016;
34:1421-6. [PMID:
27133924 DOI:
10.1016/j.ajem.2016.04.016]
[Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 04/02/2016] [Accepted: 04/08/2016] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION
Although cardiac stress testing may help establish the safety of early discharge in patients with suspected acute coronary syndromes and negative troponins, more cost-effective strategies are necessary. We aimed to develop a clinical prediction rule to safely obviate the need for cardiac stress testing in this setting.
METHODS
A decision rule was derived in a prospective cohort of 3001 patients with acute chest pain and negative troponins, and validated in a set of 1473 subjects. The primary end point was a composite of positive cardiac stress testing (in the absence of a subsequent negative coronary angiogram), positive coronary angiography, or any major coronary events within 3 months.
RESULTS
A score chart was built based on 7 variables: male sex (+2), age (+1 per decade from the fifth decade), diabetes mellitus (+2), hypercholesterolemia (+1), prior coronary revascularization (+2), type of chest pain (typical angina, +5; non-specific chest pain, -3), and non-diagnostic repolarization abnormalities (+2). In the validation set, the model showed good discrimination (c statistic = 0.84; 95% confidence interval, 0.82-0.87) and calibration (Hosmer-Lemeshow goodness-of-fit test, P= .34). If stress tests were avoided in patients in the validation sample with a sum score of 0 or lower, the number of referrals would be reduced by 23.4%, yielding a negative predictive value of 98.8% (95% confidence interval, 97.0%-99.7%).
CONCLUSION
This novel prediction rule based on a combination of readily available clinical characteristics may be a valuable tool to decide whether stress testing can be reliably avoided in patients with acute chest pain and negative troponins.
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