Comparison of the GRACE, HEART and TIMI score to predict major adverse cardiac events in chest pain patients at the emergency department.
BACKGROUND
The performance of the GRACE, HEART and TIMI scores were compared in predicting the probability of major adverse cardiac events (MACE) in chest pain patients presenting at the emergency department (ED), in particular their ability to identify patients at low risk.


METHODS
Chest pain patients presenting at the ED in nine Dutch hospitals were included. The primary outcome was MACE within 6weeks. The HEART score was determined by the treating physician at the ED. The GRACE and TIMI score were calculated based on prospectively collected data. Performance of the scores was compared by calculating AUC curves. Additionally, the number of low-risk patients identified by each score were compared at a fixed level of safety of at least 95% or 98% sensitivity.


RESULTS
In total, 1748 patients were included. The AUC of GRACE, HEART, and TIMI were 0.73 (95% CI: 0.70-0.76%), 0.86 (95% CI: 0.84-0.88%) and 0.80 (95% CI: 0.78-0.83%), respectively (all differences in AUC highly statistically significant). At an absolute level of safety of at least 98% sensitivity, the GRACE score identified 231 patients as "low risk" in which 2.2% a MACE was missed; the HEART score identified 381 patients as "low risk" with 0.8% missed MACE. The TIMI score identified no "low risk" patients at this safety level.


CONCLUSIONS
The HEART score outperformed the GRACE and TIMI scores in discriminating between those with and without MACE in chest pain patients, and identified the largest group of low-risk patients at the same level of safety.
Julius Center for Health Sciences and Primary care, University Medical Center Utrecht, Utrecht, The Netherlands. Electronic address: j.poldervaart@umcutrecht.nl.
J M
JM
Poldervaart
Department of Internal Medicine, Gelderse vallei hospital, Ede, The Netherlands.
M
M
Langedijk
Department of Emergency Medicine, Medical Center Haaglanden, Den Haag, The Netherlands.
B E
BE
Backus
Department of Emergency Medicine, Atrium Medical Center, Heerlen, The Netherlands.
I M C
IMC
Dekker
Department of Cardiology, Zuwe Hofpoort Hospital, Woerden, The Netherlands.
A J
AJ
Six
Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands.
P A
PA
Doevendans
Julius Center for Health Sciences and Primary care, University Medical Center Utrecht, Utrecht, The Netherlands.
A W
AW
Hoes
Julius Center for Health Sciences and Primary care, University Medical Center Utrecht, Utrecht, The Netherlands.
J B
JB
Reitsma
D000368:Aged; D000369:Aged, 80 and over; D002637:Chest Pain / Q000175:diagnosis* / Q000453:epidemiology*; D004636:Emergency Service, Hospital; D005260:Female; D005500:Follow-Up Studies; D006331:Heart Diseases / Q000175:diagnosis* / Q000453:epidemiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D014218:Triage / Q000379:methods
Acute coronary syndrome; Chest pain; Clinical prediction rule; GRACE score; HEART score; TIMI score