title: Biomarkers after risk stratification in acute chest pain (from the BRIC Study).
abstract: Current models incompletely risk-stratify patients with acute chest pain. In this study, N-terminal pro-B-type natriuretic peptide and cystatin C were incorporated into a contemporary chest pain triage algorithm in a clinically stratified population to improve acute coronary syndrome discrimination. Adult patients with chest pain presenting without myocardial infarction (n = 382) were prospectively enrolled from 2008 to 2009. After clinical risk stratification, N-terminal pro-B-type natriuretic peptide and cystatin C were measured and standard care was performed. The primary end point was the result of a clinical stress test. The secondary end point was any major adverse cardiac event at 6 months. Associations were determined through multivariate stratified analyses. In the low-risk group, 76 of 78 patients with normal levels of the 2 biomarkers had normal stress test results (negative predictive value 97%). Normal biomarkers predicted normal stress test results with an odds ratio of 10.56 (p = 0.006). In contrast, 26 of 33 intermediate-risk patients with normal levels of the 2 biomarkers had normal stress test results (negative predictive value 79%). Biomarkers and stress test results were not associated in the intermediate-risk group (odds ratio 2.48, p = 0.09). There were 42 major adverse cardiac events in the overall cohort. No major adverse cardiac events occurred at 6 months in the low-risk subgroup that underwent stress testing. In conclusion, N-terminal pro-B-type natriuretic peptide and cystatin C levels predict the results of stress tests in low-risk patients with chest pain but should not be substituted for stress testing in intermediate-risk patients. There is potential for their use in the early discharge of low-risk patients after clinical risk stratification.
authors.affiliation: Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai School of Medicine, New York, New York, USA.
authors.forename: Shiny
authors.initials: S
authors.lastname: Mathewkutty
authors.forename: Sanjum S
authors.initials: SS
authors.lastname: Sethi
authors.forename: Ashish
authors.initials: A
authors.lastname: Aneja
authors.forename: Kshitij
authors.initials: K
authors.lastname: Shah
authors.forename: Rupa L
authors.initials: RL
authors.lastname: Iyengar
authors.forename: Luke
authors.initials: L
authors.lastname: Hermann
authors.forename: Sayyar
authors.initials: S
authors.lastname: Khakimov
authors.forename: Louai
authors.initials: L
authors.lastname: Razzouk
authors.forename: Ricardo
authors.initials: R
authors.lastname: Esquitin
authors.forename: Rajesh
authors.initials: R
authors.lastname: Vedanthan
authors.forename: Terrie-Ann
authors.initials: TA
authors.lastname: Benjamin
authors.forename: Marie
authors.initials: M
authors.lastname: Grace
authors.forename: Rosane
authors.initials: R
authors.lastname: Nisenbaum
authors.forename: Krishnan
authors.initials: K
authors.lastname: Ramanathan
authors.forename: Lakshmi
authors.initials: L
authors.lastname: Ramanathan
authors.forename: James
authors.initials: J
authors.lastname: Chesebro
authors.forename: Michael E
authors.initials: ME
authors.lastname: Farkouh
mesh_terms: D059787:Acute Pain / Q000097:blood* / Q000175:diagnosis / Q000209:etiology; D015415:Biomarkers / Q000097:blood*; D002637:Chest Pain / Q000097:blood* / Q000175:diagnosis / Q000209:etiology; D055316:Cystatin C / Q000097:blood; D003937:Diagnosis, Differential; D004636:Emergency Service, Hospital; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology; D020097:Natriuretic Peptide, Brain / Q000097:blood; D010446:Peptide Fragments / Q000097:blood; D011379:Prognosis; D011498:Protein Precursors; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D014218:Triage; D014481:United States / Q000453:epidemiology
chemical_list: D015415:Biomarkers; D055316:Cystatin C; D010446:Peptide Fragments; D011498:Protein Precursors; C109794:pro-brain natriuretic peptide (1-76); D020097:Natriuretic Peptide, Brain