title: Comparing HEART, TIMI, and GRACE scores for prediction of 30-day major adverse cardiac events in high acuity chest pain patients in the emergency department.
abstract: BACKGROUND
  The HEART, TIMI, and GRACE scores have been applied in the Emergency Department (ED) to risk stratify patients with undifferentiated chest pain. This study aims to compare the accuracy of HEART, TIMI, and GRACE for the prediction of major adverse cardiac events (MACE) in high acuity chest pain patients.
  
  
  METHODS
  Adult patients who presented with chest pain suggestive of cardiac origin in the most acute triage category at an academic ED from September 2010 to October 2015 were included. The HEART, TIMI, and GRACE scores were calculated retrospectively from prospectively collected data. The primary outcome was occurrence of MACE (mortality, AMI, PCI, CABG) within 30-days of initial presentation.
  
  
  RESULTS
  604 patients were included in the study. Patient demographics include an average age of 61years, 69% male, and 48% with history of ischemic heart disease. 36% of patients met the primary outcome. The c-statistics of HEART, TIMI, and GRACE were 0.78 (95% CI: 0.74-0.81), 0.65 (95% CI: 0.60-0.69), and 0.62 (95% CI: 0.58-0.67), respectively. For the purpose of accurately ruling out patients for 30-day MACE, a HEART score of ≤3 had a sensitivity and NPV of 99% and 98%, respectively, compared to 97% and 91%, respectively, for TIMI=0, and 94% and 85%, respectively, for GRACE ≤75. The percent of patients with 30-day MACE with HEART scores between 0 and 3, 4-6, and 7-10 was 2%, 28%, and 63%, respectively.
  
  
  CONCLUSIONS
  In high acuity chest pain patients, the HEART score is superior to the TIMI and GRACE scores in predicting 30-day MACE.
authors.affiliation: Duke University School of Medicine, USA.
authors.forename: Jeffrey Tadashi
authors.initials: JT
authors.lastname: Sakamoto
authors.affiliation: Department of Emergency Medicine, Singapore General Hospital, Singapore; Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore. Electronic address: liu.nan@sgh.com.sg.
authors.forename: Nan
authors.initials: N
authors.lastname: Liu
authors.affiliation: Department of Emergency Medicine, Singapore General Hospital, Singapore.
authors.forename: Zhi Xiong
authors.initials: ZX
authors.lastname: Koh
authors.affiliation: Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: Nicholas Xue Jin
authors.initials: NX
authors.lastname: Fung
authors.affiliation: Faculty of Medical Sciences, University of Groningen, The Netherlands.
authors.forename: Micah Liam Arthur
authors.initials: ML
authors.lastname: Heldeweg
authors.affiliation: Department of Emergency Medicine, Singapore General Hospital, Singapore.
authors.forename: Janson Cheng Ji
authors.initials: JC
authors.lastname: Ng
authors.affiliation: Department of Emergency Medicine, Singapore General Hospital, Singapore; Health Services and Systems Research, Duke-NUS Medical School, Singapore.
authors.forename: Marcus Eng Hock
authors.initials: ME
authors.lastname: Ong
mesh_terms: D000367:Age Factors; D000368:Aged; D001794:Blood Pressure / Q000502:physiology; D002637:Chest Pain / Q000175:diagnosis* / Q000453:epidemiology / Q000503:physiopathology; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D006331:Heart Diseases / Q000175:diagnosis* / Q000453:epidemiology / Q000503:physiopathology; D006339:Heart Rate / Q000502:physiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods / Q000592:standards; D012720:Severity of Illness Index; D013997:Time Factors; D014218:Triage / Q000379:methods / Q000592:standards
keywords: Chest pain; Emergency department; GRACE; HEART; Risk score; TIMI