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Chest Pain Scores
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
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Chest Pain Scores
- 1. Kristopher Maday, MS,PA-C Program Director/Associate Professor University of Tennessee Health Science Center Physician Assistant Program
- 2. Walker G. EMNews. 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
- 3. • PURSUIT • TIMI •GRACE • FRISC • HEART • EDACS
- 5. • Published in2000 • 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
- 6. Boersma E. Circulation.2000;101(22):2557-2567 I will cath you ≥ 20%
- 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
- 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%
- 13.
- 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 PreviousAMI ST depression Elevated troponin Elevated CRP/IL-6 Lagerqvist B. Heart. 2005;91(8):1047-1052 I will cath you ≥ 3
- 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. NethHeart J. 2008;16(6):191-196 Rezaie S. REBEL EM Blog. 2014.
- 19. • Published in2014 • 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
- 20. Than M. EmergMed Australas. 2014;26(1):34-44
- 21. Than M. EmergMed 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
- 22. • Risk stratification •Discharge low risk chest pain • Use clinical gestalt
- 23. w w w. p a i n e p o d c a s t . c o m
Editor's Notes
- #3 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?
- #6 Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin (eptifibatide) Therapy
- #7 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
- #10 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)
- #12 Both STEMI and NSTEMI
- #13 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
- #17 Like TIMI, is simple to use but has a poor predictive power (i.e. c-statistic 0.70)
- #21 Emergency Department Assessment of Chest pain Score