title: Combination of clinical risk profile, early exercise testing and circulating biomarkers for evaluation of patients with acute chest pain without ST-segment deviation or troponin elevation.
abstract: OBJECTIVE
  To investigate the combination of clinical data, exercise testing and biomarkers for the evaluation of patients with chest pain without ST-segment deviation or troponin elevation.
  
  
  METHODS
  Prospective cohort design. SETTTING: Two teaching hospitals in Spain.
  
  
  METHODS
  422 patients presenting to the emergency department were studied. Leukocyte count, C-reactive protein (CRP), pregnancy-associated plasma protein A (PAPP-A) and N-terminal pro-brain natriuretic peptide (NT-proBNP) were determined. A validated clinical risk score (number of points according to pain characteristics and risk factors) was used for clinical evaluation and early exercise testing was performed.
  
  
  METHODS
  Adverse events (death, myocardial infarction or revascularisation) during a median 60 weeks follow-up.
  
  
  RESULTS
  By receiver operating characteristic curve analysis, the association between death or myocardial infarction and adverse events was not significant with leukocyte count (p = 0.3, p = 0.3) or CRP (p = 0.5, p = 0.8), was borderline significant with PAPP-A (p = 0.07, p = 0.04) and strongly significant with NT-pro-BNP (p = 0.0001, p = 0.0001). By Cox regression including clinical risk score, exercise testing result and biomarkers, exercise testing was the independent predictor of revascularisation (p = 0.0001), whereas risk score (p = 0.03) and NT-proBNP (p = 0.0004) predicted death or myocardial infarction. The inclusion of NT-proBNP improved the accuracy of the model for death or myocardial infarction (C-statistic 0.84 versus 0.76, p = 0.01). The combination of clinical score and NT-proBNP afforded the stratification in high (17.2%, p = 0.0001), intermediate (5.3%) and low (1.1%) risk categories of death or myocardial infarction.
  
  
  CONCLUSIONS
  NT-proBNP provides incremental prognostic information above that given by clinical history and exercise testing in patients with chest pain without ST-segment deviation and negative troponin.
authors.affiliation: Servei de Cardiologia, Hospital Clínic Universitari, Universitat de València, València, Spain. sanchis_juafor@gva.es
authors.forename: J
authors.initials: J
authors.lastname: Sanchis
authors.forename: X
authors.initials: X
authors.lastname: Bosch
authors.forename: V
authors.initials: V
authors.lastname: Bodí
authors.forename: N
authors.initials: N
authors.lastname: Bellera
authors.forename: J
authors.initials: J
authors.lastname: Núñez
authors.forename: B
authors.initials: B
authors.lastname: Benito
authors.forename: J
authors.initials: J
authors.lastname: Ordóñez
authors.forename: L
authors.initials: L
authors.lastname: Consuegra
authors.forename: M
authors.initials: M
authors.lastname: Heras
authors.forename: A
authors.initials: A
authors.lastname: Llècer
mesh_terms: D015415:Biomarkers / Q000097:blood; D002637:Chest Pain / Q000097:blood* / Q000401:mortality; D004812:Epidemiologic Methods; D005080:Exercise Test; D006801:Humans; D008875:Middle Aged; D009203:Myocardial Infarction / Q000097:blood* / Q000401:mortality; D020097:Natriuretic Peptide, Brain / Q000097:blood; D010446:Peptide Fragments / Q000097:blood; D014336:Troponin / Q000097:blood*
chemical_list: D015415:Biomarkers; D010446:Peptide Fragments; D014336:Troponin; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain