Kristopher Maday, MS, PA-C is the Program Director and Associate Professor at the University of Tennessee Health Science Center Physician Assistant Program. He provided a summary of several risk scores used to risk stratify patients presenting with chest pain including the PURSUIT, TIMI, GRACE, FRISC, HEART, and EDACS scores. Several of these scores such as GRACE and TIMI were developed and validated in large international randomized controlled trials to predict short and long term risks of death and myocardial infarction. The FRISC trial examined the benefit of early revascularization in unstable coronary syndrome patients. The EDACS score was derived and validated in two hospital studies to predict low risk in an accelerated
1. Kristopher Maday, MS, PA-C
Program Director/Associate Professor
University of Tennessee Health Science Center
Physician Assistant Program
2. Walker G. EM News. 2015;37(8):310-32
1 : 1816 1 : 160
30hr per week
50wk per year
2.5 patients per hour
5-10% chest pain patients
Every chest pain patient for 5 years to prevent one bad outcome
5. • Published in 2000
• Aim
– Predict 30-day risk of death/AMI in patients
with ACS
• Design
– 9461 patients
– 726 hospitals in 28 countries
Boersma E. Circulation. 2000;101(22):2557-2567
8. • Original Study
– Published in 2000
– Aim
• Create simple risk score for UA/NSTEMI to predict
14-day risk of all cause mortality, AMI, or need for
urgent revascularization
– Design
• 7081 patients
– Combined patients from TIMI 11b and ESSENCE trial
• International, randomized, double-blind
• Validated in 2006
Antman EM. JAMA. 2000;282(7):835-842 Pollack CV. Acad Emerg Med. 2006;13(1):13-18
9. Antman EM. JAMA. 2000;282(7):835-842
Age ≥ 65
≥ 3 CAD Risk Factors
≥ 2 episodes of severe angina in past 24hr
ASA Use in Past 7 days
Known CAD (≥50% stenosis)
ST changes ≥ 0.5mm on EKG
(+) Cardiac Enzyme
(+) FH of CAD
HTN
HLD
DM
(+) smoker
I will cath you
≥ 4
10.
11. • Original Study
– Published in 2006
– Aim
• Predict 6-month risk of death/AMI in patients with
ACS
– Design
• 43810 patients
• 94 hospitals in 14 countries
• Validated in 2009
Fox KA. BMJ. 2006;333(7578):1091 Elbarouni B. Am Heart J. 2009;158(3):392-299
12. Fox KA. BMJ. 2006;333(7578):1091 Elbarouni B. Am Heart J. 2009;158(3):392-299
GRACE Score Mortality Risk
0-87 0-2%
88-128 3-10%
129-149 10-20%
150-173 20-30%
174-182 40%
183-190 50%
200-207 70%
208-284 90%
≥ 285 99%
14. • 1999 – Original study
– Primary Aim
• Early vs traditional revacularization in chest pain
patients
• 58 Scandanavian hospitals
• 2457 patients
• 2005 – Analyzed independent variables
– Primary aim
• Identification of chest pain patients who would most
benefit from early revascularization
FRISC II Investigators. Lancet. 1999;354:708–715 Lagerqvist B. Heart. 2005;91(8):1047-1052
15. Age ≥ 70
Male
Diabetes
Previous AMI
ST depression
Elevated troponin
Elevated CRP/IL-6
Lagerqvist B. Heart. 2005;91(8):1047-1052
I will cath you
≥ 3
16.
17. • Original Study
– Published in 2008
– Aim
• Develop risk score for chest pain patients
presenting to the ED
– Design
• 122 patients, single center study
• Validated in 2013
Six AJ. Neth Heart J. 2008;16(6):191-196 Backus BE. Int J Cardiol. 2013;168 (3):2153-2158
18. Six AJ. Neth Heart J. 2008;16(6):191-196 Rezaie S. REBEL EM Blog. 2014.
19. • Published in 2014
• Aim
– Derive a chest pain score for an accelerated
diagnostic protocol
• Design
– 1974 patients
– 2 hospitals
• Self-validated with additional 608 patients
Than M. Emerg Med Australas. 2014;26(1):34-44
21. Than M. Emerg Med Australas. 2014;26(1):34-44
Low Risk
EDACS < 16 AND no ischemia on EKG AND 0/2hr troponin (-)
Not Low Risk
EDACS ≥ 16 OR new ischemia on EKG OR 0/2hr troponin (+)
I will cath you
http://journals.lww.com/em-news/Fulltext/2015/08000/Emergentology__Trust_Your_Gut_When_It_Comes_to.2.aspx
This paper then goes on to think about the risk and harm to these 7,266 patients (when only one in 1,816 had a relevant bad outcome), given estimates of harm to hospitalizing patients around one in 160.
If you work 30 hours a week for 50 weeks a year and see 2.5 patients an hour, and five to 10 percent of patients come to the ED for chest pain, you'd have to admit all of these “I'm not too worried” chest pains for almost five years of your career to help one of them. Did I mention the complication rate of cath is at least one percent?
Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin (eptifibatide) Therapy
Canadian Cardiovascular Society Does not include troponin assays as part of score and the majority of the score is dependent on patient age.
I – strenous exertional angina
II – moderate exertional angina
III – mild exertional angina
IV – rest angina
TIMI score patients are divided into low (score 0-2), intermediate (score 3-4) and high (score 5-7) risk categories
Simple to use, but has a poor predictive power (i.e. c-statistic 0.65)
Both STEMI and NSTEMI
Very complex to use and a large portion of the score is dependent on the patient age. Also patients not divided into different risk groups
Like TIMI, is simple to use but has a poor predictive power (i.e. c-statistic 0.70)
Emergency Department Assessment of Chest pain Score