Risk stratification of patients with acute chest pain and normal troponin concentrations

Abstract

Objective: To investigate the outcome of patients with acute chest pain and normal troponin concentrations. Design: Prospective cohort design. Setting: Single centre study in a teaching hospital in Spain. Patients: 609 consecutive patients with chest pain evaluated in the emergency department by clinical history (risk factors and a chest pain score according to pain characteristics), ECG, and early (, 24 hours) exercise testing for low risk patients with physical capacity (n = 283, 46%). All had normal troponin concentrations after serial determination. Main outcome measures: Myocardial infarction or cardiac death during six months of follow up. Results: 29 events were detected (4.8%). No patient with a negative early exercise test (n = 161) had events versus the 6.9% event rate in the remaining patients (p = 0.0001). Four independent predictors were found: chest pain score > 11 points (odds ratio (OR) 2.4, 95% confidence interval (CI) 1.1 to 5.5, p = 0.04), diabetes mellitus (OR 2.3, 95% CI 1.1 to 4.7, p = 0.03), previous coronary surgery (OR 3.1, 95% CI 1.3 to 7.6, p = 0.01), and ST segment depression (OR 2.8, 95% CI 1.3 to 6.3, p = 0.003). A risk score proved useful for patient stratification according to the presence of 0-1 (2.7% event rate), 2 (10.2%, p = 0.008), and 3-4 predictors (29.2%, p = 0.0001). Conclusions: A negative troponin result does not assure a good prognosis for patients coming to the emergency room with chest pain. Early exercise testing and clinical data should be carefully evaluated for risk stratification.

Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule

“…17 Scores developed in emergency departments include a broad range of different variables, including age, sex, risk factors and pain characteristics. 12,[21][22][23][24] One study determined the usefulness of pain reproduced by palpation of the chest wall for defining low-risk patients. 11 However, most of these studies used other reference diagnoses such as acute coronary syndromes, and all were performed in a setting where the prevalence of coronary artery disease is much higher than that in a primary care setting.…”

Use of multidetector computed tomography for the assessment of acute chest pain: a consensus statement of the North American Society of Cardiac Imaging and the European Society of Cardiac Radiology

“…A risk score for patients with normal troponin concentrations has recently been proposed [22,23]. Specific recommendations for an early invasive strategy in patients with NSTEMI include any of the following high-risk indicators [24]:…”

Clinical risk scoring beyond initial troponin values: Results from a large, prospective, unselected acute chest pain population

“…These patients may represent a clinically important subgroup of either high-or low-risk patients, whose impact on the final predictive model remains indeterminate. The list of candidate variables chosen for analysis in the derivation of the risk score was not exhaustive and did not include other variables that have previously been shown to predict adverse cardiac events associated with acute chest pain syndromes (8,9,21,28,29). However, we sought to capture those characteristics with the greatest clinical relevance and potential predictive capacity.…”

“…However, despite their widespread use, the use of troponin measurements as part of a more comprehensive risk factor model is not well established for the broad spectrum of patients who present to hospitals with chest pain (1,11,14,20). Moreover, emerging data suggest that although a negative troponin measurement is associated with lower short-term risk, it does not necessarily identify a 'low-risk' patient subset (21).…”