title: A clinical score to obviate the need for cardiac stress testing in patients with acute chest pain and negative troponins.
abstract: BACKGROUND
  Although cardiac stress testing may help establish the safety of early discharge in patients with suspected acute coronary syndromes and negative troponins, more cost-effective strategies are necessary. We aimed to develop a clinical prediction rule to safely obviate the need for cardiac stress testing in this setting.
  
  
  METHODS
  A decision rule was derived in a prospective cohort of 3001 patients with acute chest pain and negative troponins, and validated in a set of 1473 subjects. The primary end point was a composite of positive cardiac stress testing (in the absence of a subsequent negative coronary angiogram), positive coronary angiography, or any major coronary events within 3 months.
  
  
  RESULTS
  A score chart was built based on 7 variables: male sex (+2), age (+1 per decade from the fifth decade), diabetes mellitus (+2), hypercholesterolemia (+1), prior coronary revascularization (+2), type of chest pain (typical angina, +5; non-specific chest pain, -3), and non-diagnostic repolarization abnormalities (+2). In the validation set, the model showed good discrimination (c statistic = 0.84; 95% confidence interval, 0.82-0.87) and calibration (Hosmer-Lemeshow goodness-of-fit test, P= .34). If stress tests were avoided in patients in the validation sample with a sum score of 0 or lower, the number of referrals would be reduced by 23.4%, yielding a negative predictive value of 98.8% (95% confidence interval, 97.0%-99.7%).
  
  
  CONCLUSIONS
  This novel prediction rule based on a combination of readily available clinical characteristics may be a valuable tool to decide whether stress testing can be reliably avoided in patients with acute chest pain and negative troponins.
authors.affiliation: Department of Cardiology, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain. Electronic address: alberto.bouzas.mosquera@sergas.es.
authors.forename: Alberto
authors.initials: A
authors.lastname: Bouzas-Mosquera
authors.affiliation: Department of Cardiology, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain.
authors.forename: Jesús
authors.initials: J
authors.lastname: Peteiro
authors.affiliation: Department of Information Technology, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain.
authors.forename: Francisco J
authors.initials: FJ
authors.lastname: Broullón
authors.affiliation: Department of Cardiology, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain.
authors.forename: Nemesio
authors.initials: N
authors.lastname: Álvarez-García
authors.affiliation: Department of Cardiology, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain.
authors.forename: Nicolás
authors.initials: N
authors.lastname: Maneiro-Melón
authors.affiliation: Department of Cardiology, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain.
authors.forename: Patricia
authors.initials: P
authors.lastname: Pardo-Martinez
authors.affiliation: Department of Cardiology, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain.
authors.forename: Marta
authors.initials: M
authors.lastname: Sagastagoitia-Fornie
authors.affiliation: Department of Cardiology, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain.
authors.forename: Dolores
authors.initials: D
authors.lastname: Martínez
authors.affiliation: Department of Cardiology, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain.
authors.forename: Juan C
authors.initials: JC
authors.lastname: Yáñez
authors.affiliation: Department of Cardiology, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain.
authors.forename: José Manuel
authors.initials: JM
authors.lastname: Vázquez-Rodríguez
mesh_terms: D002637:Chest Pain / Q000175:diagnosis* / Q000453:epidemiology; D017023:Coronary Angiography; D003661:Decision Support Techniques; D003937:Diagnosis, Differential; D004562:Electrocardiography; D004636:Emergency Service, Hospital; D005080:Exercise Test / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors