Document Detail

Limitations of risk score models in patients with acute chest pain.
MedLine Citation:
PMID:  19041532     Owner:  NLM     Status:  MEDLINE    
OBJECTIVES: Cardiac multidetector computed tomography (CMCT) has potential to be used as a screening test for patients with acute chest pain, but several tools are already used to risk-stratify this population. Risk models exist that stratify need for intensive care (Goldman), short-term prognosis (Thrombolysis in Myocardial Infarction, TIMI), and 1-year events (Sanchis). We applied these cardiovascular risk models to candidates for CMCT and assessed sensitivity for prediction of in-hospital acute coronary syndrome (ACS). We hypothesized that none of the models would achieve a sensitivity of 90% or greater, thereby justifying use of CMCT in patients with acute chest pain. METHODS: We analyzed TIMI, Goldman, and Sanchis in 148 consecutive patients with chest pain, nondiagnostic electrocardiogram, and negative initial cardiac biomarkers who previously met inclusion and exclusion criteria for the Rule-Out Myocardial Infarction Using Coronary Artery Tomography Study. ACS was adjudicated, and risk scores were categorized based on established criteria. Risk score agreement was assessed with weighted kappa statistics. RESULTS: Overall, 17 (11%) of 148 patients had ACS. For all risk models, sensitivity was poor (range, 35%-53%), and 95% confidence intervals did not cross above 77%. Agreement to risk-classify patients was poor to moderate (weighted kappa range, 0.18-0.43). Patients categorized as "low risk" had nonzero rates of ACS using all 3 scoring models (range, 8%-9%). CONCLUSIONS: Available risk scores had poor sensitivity to detect ACS in patients with acute chest pain. Because of the small number of patients in this data set, these findings require confirmation in larger studies.
Alex F Manini; Nina Dannemann; David F Brown; Javed Butler; Fabian Bamberg; John T Nagurney; John H Nichols; Udo Hoffmann;
Publication Detail:
Type:  Journal Article; Research Support, N.I.H., Extramural; Research Support, Non-U.S. Gov't    
Journal Detail:
Title:  The American journal of emergency medicine     Volume:  27     ISSN:  1532-8171     ISO Abbreviation:  Am J Emerg Med     Publication Date:  2009 Jan 
Date Detail:
Created Date:  2008-12-01     Completed Date:  2009-01-02     Revised Date:  2009-04-16    
Medline Journal Info:
Nlm Unique ID:  8309942     Medline TA:  Am J Emerg Med     Country:  United States    
Other Details:
Languages:  eng     Pagination:  43-8     Citation Subset:  IM    
Harvard Affiliated Emergency Medicine Residency, Department of Emergency Medicine at Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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MeSH Terms
Acute Coronary Syndrome / complications,  diagnosis*,  radiography
Chest Pain / etiology*
Middle Aged
Myocardial Infarction / complications,  diagnosis*,  radiography
Prospective Studies
Risk Assessment
Risk Factors
Severity of Illness Index*
Tomography, X-Ray Computed
Grant Support
Comment In:
Am J Emerg Med. 2009 Mar;27(3):365-6; author reply 366-7   [PMID:  19328386 ]

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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