Limitations of risk score models in patients with acute chest pain.
OBJECTIVE
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.
Manini
Alex F
AF
Harvard Affiliated Emergency Medicine Residency, Boston, MA, USA. Electronic address: alex.manini@nyumc.org.
Dannemann
Nina
N
Cardiac MR PET CT Program, Harvard Medical School, Boston, MA, USA.
Brown
David F
DF
Department of Emergency Medicine at Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
Butler
Javed
J
Cardiac MR PET CT Program, Harvard Medical School, Boston, MA, USA.
Bamberg
Fabian
F
Cardiac MR PET CT Program, Harvard Medical School, Boston, MA, USA.
Nagurney
John T
JT
Department of Emergency Medicine at Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
Nichols
John H
JH
Cardiac MR PET CT Program, Harvard Medical School, Boston, MA, USA.
Hoffmann
Udo
U
Cardiac MR PET CT Program, Harvard Medical School, Boston, MA, USA.
D054058:Acute Coronary Syndrome / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging; D000328:Adult; D000368:Aged; D002637:Chest Pain / Q000209:etiology*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging; D011379:Prognosis; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed