title: Chest pain in the emergency department: risk stratification with Manchester triage system and HEART score.
abstract: BACKGROUND
  Fast and accurate chest pain risk stratification in the emergency department (ED) is critical. The HEART score predicts the short-term incidence of major adverse cardiac events (MACE) in this population, dividing it in three risk categories. We aimed to describe the population with chest pain, to characterize the subgroup of patients with acute coronary syndrome (ACS) and to assess the prognostic value of Manchester triage system and of HEART score.
  
  
  METHODS
  Retrospective observational study including patients admitted to the ED of a tertiary hospital with chest pain as the presenting symptom. The primary outcome was a composite of all-cause mortality, myocardial infarction or unscheduled revascularization at 6 weeks.
  
  
  RESULTS
  We enrolled 233 patients (age 58 ± 19; 55.4 % males). The most common final diagnosis was non-specific chest pain (n = 86, 36.9 %), followed by ACS (n = 22, 9.4 %). Male gender, smoking and chronic kidney disease were associated with higher risk of ACS. According to Manchester triage system, chest pain patients stratified with red or orange priority had a higher incidence of ACS (16.5 % vs. 3.8 %, p = 0.006). The application of HEART score showed that most patients were in low risk category (56.3 %). The six-week incidence of MACE in each category was 2 %, 15.6 % and 76.9 % (p < 0.001). HEART score accurately predicted the short-term incidence of MACE in chest pain patients (c-statistic 0.880; 95 % CI, 0.807-0.950, p < 0.001).
  
  
  CONCLUSIONS
  Chest pain patients have very different levels of severity and the discriminatory power of Manchester triage system should be used in the assessment of this population. The HEART score seems to be an effective tool for risk stratification in the ED.
authors.affiliation: Departament of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal. luispcleite@gmail.com.
authors.forename: Luís
authors.initials: L
authors.lastname: Leite
authors.affiliation: Departament of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal. ruibaptista@gmail.com.
authors.forename: Rui
authors.initials: R
authors.lastname: Baptista
authors.affiliation: Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal. jorge.a.leitao@gmail.com.
authors.forename: Jorge
authors.initials: J
authors.lastname: Leitão
authors.affiliation: Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal. joana.cochicho@gmail.com.
authors.forename: Joana
authors.initials: J
authors.lastname: Cochicho
authors.affiliation: Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal. filipebreda82@gmail.com.
authors.forename: Filipe
authors.initials: F
authors.lastname: Breda
authors.affiliation: Departament of Cardiology, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal. luisdvelvas@netcabo.pt.
authors.forename: Luís
authors.initials: L
authors.lastname: Elvas
authors.affiliation: Emergency Department, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal. isabelalbuquerque1@sapo.pt.
authors.forename: Isabel
authors.initials: I
authors.lastname: Fonseca
authors.affiliation: Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal. aspcarvalho@gmail.com.
authors.forename: Armando
authors.initials: A
authors.lastname: Carvalho
authors.affiliation: Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Praceta Prof. Mota Pinto, Coimbra, 3000-075, Portugal. nascimentocosta@netcabo.pt.
authors.forename: José Nascimento
authors.initials: JN
authors.lastname: Costa
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis*; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000787:Angina Pectoris / Q000209:etiology; D002637:Chest Pain / Q000209:etiology*; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors; D012737:Sex Factors; D014218:Triage / Q000379:methods*