Chest Pain Risk Stratification in the Emergency Department: Current Perspectives.
Chest Pain Risk Stratification in the Emergency Department: Current Perspectives.
Less than 10% of patients with chest pain are diagnosed with acute coronary syndrome.
A low risk for chest pain is a 30-day risk of death or major adverse cardiac events (MACE), which is less than 1%.
Clinical assessment of patients with the utility of history, physical examination, or initial diagnostic tools, such as the electrocardiogram (EKG) or cardiac biomarkers, have been traditionally used methods to distinguish low-risk patients from patients with ACS; however, none of these methods can reliably rule in or exclude ACS. To meet this challenge, several clinical risk scores (eg, HEART, TIMI, etc.) have emerged for risk stratification of patients to evaluate suspected ACS.8 Recently, a new biomarker, high-sensitivity cardiac troponin (hs-cTn), has further enhanced the chest pain risk stratification, allowing for a rapid rule-in and rule-out strategy.
Cardiac Biomarkers:
cTn and Hs-cTn
Cardiovascular biomarkers play a crucial role in evaluating chest pain for the diagnosis of acute myocardial infarction (AMI), risk stratification, and differentiation of cardiac and non-cardiac causes. Cardiac troponins (cTn-I and cTn-T) are cardiac-specific enzymes.
Although creatine kinase MB (CK-MB) and myoglobin are also widely used cardiac enzymes, cTn is preferred for chest pain assessment for being superior to these enzymes.
The greater sensitivity and negative predictive value (NPV) of hs-cTn assays compared with cTn have led to the widespread adoption of hs-cTn as the preferred biomarker to rule out patients in ED. In addition, the higher sensitivity of hs-cTn assays provides a shorter time interval to the second measurement of troponin, significantly reducing the time to diagnosis and improving efficiency in the ED. Older-generation assays often require a longer time interval between troponin measurements to allow for a sufficient increase in troponin levels for detection. However, with hs-cTn assays, detecting even small changes in troponin levels is possible, allowing for a more rapid diagnosis of AMI.9,12 0/1-h protocol with hs-cTn suggested by the European Society of Cardiology (ESC) is a useful risk assessment tool for emergency physicians to rapidly rule out AMI.
D-dimer, a widely used noncardiac biomarker, holds significance in the comprehensive evaluation of patients presenting with chest pain. D-dimer should be part of initial assessment, especially if clinical suspicion is high for aortic dissection or pulmonary embolisms.
Because of having high sensitivity, VCPR helps physicians to identify low-risk patients with chest pain who could be safely discharged from the ED without further cardiac testing. The new VCPR score, an updated tool, was created using cTn instead of CK-MB and showed 99.2% sensitivity for 30-day ACS. For both the original VCPR and new VCPR scores, if none of the criteria are met, no additional investigations are required, and patients can be discharged home.
HEART Score and the HEART Pathway
The HEART (History, EKG, Age, Risk Factors, and Troponin) score is a clinical prediction tool used to evaluate the risk of MACE in patients who present to the ED with chest pain to stratify patients into low, moderate, and high-risk groups. Each of the five components receives 0, 1, or 2 points according to the criteria with a total score of 0 to 10. A score of 0 to 3 denotes low risk, with a 6-week MACE risk of less than 2%. A score of 4–6 shows intermediate risk with a 6-week MACE risk of 12–16% and score of 7–10 indicates a high risk with a 6-week MACE risk of 50–65%. According to the study, a HEART score of 0–3 supports to discharge patients home, a score of 4–6 suggests clinical observation and score ≥7 points suggest early invasive strategy .
The HEART score has shown high sensitivity and negative predictive value for identifying low-risk patients who may be safely discharged from the ED.
The HEART score performed better in the low-risk population than other risk scores like TIMI and GRACE, with only 0.8% incidence of MACE in the low-risk group.
The HEART Pathway was created to evaluate patients with acute chest pain based on the previously validated HEART Score (Table 1). Unlike other scores such as TIMI or GRACE, the HEART Pathway is used to evaluate the risk of ACS in patients with chest pain. However, it was designed for patients presenting to the ED with chest pain and was not studied in patients who are already hospitalized for chest pain.
Rapid Rule-Out Strategy by 0/1-Hour Algorithm
A hs-cTnT 0/1-hr algorithm as suggested by ESC is an important tool as a fast rule-out and rule-in for patients with chest pain presenting to the ED. The ESC 0/1-h algorithm helps ED physicians triage patients based on hs-cTnT cutoff concentrations obtained at presentation and after 1 hr, in conjunction with clinical information and ECG findings.
however, other life-threatening conditions such as aortic dissection or pulmonary embolism need to be considered as the differential of chest pain. Moreover, the hs-cTnT 0/1-hr algorithm significantly reduces the length of stay in the ED as the median ED length of stay was reported as 2.5 hr when using 0/1-hr algorithm for patients with suspected NSTEMI.
Rapid Rule-Out Strategy by 0/3-Hour Algorithm
According to the hs-cTnT 0/3-hr algorithm, AMI is ruled out if hs-cTn concentration remains low at presentation and 3 h, and if the patient has no chest pain. The 0/3-hr algorithm can be used if patients with chest pain who have intermediate hs-cTn values or NSTEMI cannot be ruled out by the 0/1-hr algorithm.
Conclusion
Cardiac biomarkers, particularly cTn-I and cTn-T, are crucial in assessing chest pain for AMI diagnosis, risk stratification, and distinguishing cardiac from non-cardiac causes. High-sensitivity cardiac troponin assays, offering greater sensitivity and negative predictive value, have revolutionized early detection and management of patients with suspected acute coronary syndrome (ACS). The introduction of ESC hs-cTnT strategies for rapid rule-out, particularly the 0/1-hr and 0/3-hr algorithms, has shown promising results in identifying low-risk patients, allowing for early discharge. These strategies significantly reduce the length of stay in the emergency department, enhancing overall efficiency.
https://www.dovepress.com/chest-pain-risk-stratification-in-the-emergency-department-current-per-peer-reviewed-fulltext-article-OAEM
2024.
Dr Jamal Dabbas
