Risk scores prognostic implementation in patients with chest pain and nondiagnostic electrocardiograms (original) (raw)
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Clinical Research in Cardiology, 2013
Background To improve early diagnostic and therapeutic decision making, we designed the HEART score for chest pain patients in the emergency department (ED). HEART is an acronym of its components: History, ECG, Age, Risk factors and Troponin. Currently, many chest pain patients undergo exercise testing on the consecutive days after presentation. However, it may be questioned how much diagnostic value the exercise ECG adds when the HEART score is already known. Methods A subanalysis was performed of a multicenter prospective validation study of the HEART score, consisting of 248 patients who underwent exercise testing within 7 days after presentation in the ED. Outcome is the predictive value of exercise testing in terms of major adverse cardiac events (MACE) within 6 weeks after presentation. Results In low-risk patients (HEART score B3), 63.1 % were negative tests, 28.6 % non-conclusive and 8.3 % positive; the latter were all false positives. In the intermediate-risk group (HEART score 4-6), 30.9 % were negative tests, 60.3 % non-conclusive and 8.8 % positive, half of these positives were false positives. In the high-risk patients (HEART score C7), 14.3 % were negative tests, 57.1 % non-conclusive and 28.6 % positive, of which half were false positives. Conclusion In a chest pain population risk stratified with HEART, exercise testing has only a modest contribution to clinical decision making. 50 % of all tests are non-conclusive, with high rates of false positive tests in all three risk groups. In intermediate-risk patients, negative exercise tests may contribute to the exclusion of disease. Clinicians should rather go for sensitive tests, in particular in patients with low HEART scores.
Coronary Artery Disease, 2017
Background Several variables of electrocardiogram exercise testing (EET) predict cardiovascular events in the general population and in patients with coronary artery disease (CAD). However, most of the studies have not included patients with asymptomatic CAD. The aim of this study was to evaluate the prognostic value of EET in asymptomatic CAD patients. Patients and methods We carried out a retrospective single-center analysis including all patients with asymptomatic CAD documented by angiography who underwent EET from January 2010 to December 2013. A number of EET variables and three exercise scores [Duke Treadmill Score (DTS), Morise score, and FIT score] were analyzed. The primary endpoint was the combined incidence of myocardial infarction (MI), myocardial revascularization, and death from any cause during follow-up. Results A total of 306 patients were included (mean age was 65 ± 10 years, 61% had previous MI, and the median exercise capacity was 9.4 ± 2.7 metabolic equivalent of task). The primary endpoint occurred in 15.7% of patients during 3.3 years of follow-up. The DTS and FIT were independent predictors of the primary endpoint unlike the Morise score (DTS: hazard ratio = 0.91, 95% confidence interval: 0.85-0.99, P = 0.018; FIT score: 0.99, 0.98-0.996, P = 0.001; Morise score: 0.97, 0.93-1.02, P = 0.20). The DTS was independent predictor of MI or revascularization, whereas FIT predicted death from any cause. Excluding patients with early revascularization, DTS had no predictive power at the composite endpoint. Conclusion In our population with asymptomatic CAD, FIT and DTS had significant value for risk prediction and consequently the EET can be a valid tool in the clinical follow-up of this population.
BMJ, 2008
Objective To determine whether resting and exercise electrocardiograms (ECGs) provide prognostic value that is incremental to that obtained from the clinical history in ambulatory patients with suspected angina attending chest pain clinics. Design Multicentre cohort study. Setting Rapid access chest pain clinics of six hospitals in England. Participants 8176 consecutive patients with suspected angina and no previous diagnosis of coronary artery disease, all of whom had a resting ECG recorded. 4848 patients with a summary exercise ECG result recorded (positive, negative, equivocal for ischaemia) comprised the summary ECG subset of whom 1422 with more detailed exercise ECG data recorded comprised the detailed ECG subset. Main outcome measure Composite of death due to coronary heart disease or non-fatal acute coronary syndrome during median follow-up of 2.46 years. Results Receiver operating characteristics curves for the basic clinical assessment model alone and with the results of resting ECGs were superimposed with little difference in the C statistic. With the exercise ECGs the C statistic in the summary ECG subset increased from 0.70 (95% confidence interval 0.68 to 0.73) to 0.74 (0.71 to 0.76) and in the detailed ECG subset from 0.74 (0.70 to 0.79) to 0.78 (0.74 to 0.82). However, risk stratified cumulative probabilities of the primary end point at one year and six years for all three prognostic indices (clinical assessment only; clinical assessment plus resting ECG; clinical assessment plus resting ECG plus exercise ECG) showed only small differences at all time points and at all levels of risk. Conclusion In ambulatory patients with suspected angina, basic clinical assessment encompasses nearly all the prognostic value of resting ECGs and most of the prognostic value of exercise ECGs. The limited incremental value of these widely applied tests emphasises the need for more effective methods of risk stratification in this group of patients.
2008
Objective To determine whether resting and exercise electrocardiograms (ECGs) provide prognostic value that is incremental to that obtained from the clinical history in ambulatory patients with suspected angina attending chest pain clinics. Design Multicentre cohort study. Setting Rapid access chest pain clinics of six hospitals in England. Participants 8176 consecutive patients with suspected angina and no previous diagnosis of coronary artery disease, all of whom had a resting ECG recorded. 4848 patients with a summary exercise ECG result recorded (positive, negative, equivocal for ischaemia) comprised the summary ECG subset of whom 1422 with more detailed exercise ECG data recorded comprised the detailed ECG subset. Main outcome measure Composite of death due to coronary heart disease or non-fatal acute coronary syndrome during median follow-up of 2.46 years. Results Receiver operating characteristics curves for the basic clinical assessment model alone and with the results of resting ECGs were superimposed with little difference in the C statistic. With the exercise ECGs the C statistic in the summary ECG subset increased from 0.70 (95% confidence interval 0.68 to 0.73) to 0.74 (0.71 to 0.76) and in the detailed ECG subset from 0.74 (0.70 to 0.79) to 0.78 (0.74 to 0.82). However, risk stratified cumulative probabilities of the primary end point at one year and six years for all three prognostic indices (clinical assessment only; clinical assessment plus resting ECG; clinical assessment plus resting ECG plus exercise ECG) showed only small differences at all time points and at all levels of risk. Conclusion In ambulatory patients with suspected angina, basic clinical assessment encompasses nearly all the prognostic value of resting ECGs and most of the prognostic value of exercise ECGs. The limited incremental value of these widely applied tests emphasises the need for more effective methods of risk stratification in this group of patients.
The American Journal of Cardiology, 1987
The prognostic information of clinical variables and a predischarge exercise test was studied in 400 patients (282 men, 118 women) admitted to the coronary care unit with suspected unstable coronary artery disease, that is, recurring chest pain of new onset, increasing angina1 pain in formerly stable angina pectoris or suspected nontransmural acute myocardial infarction. Forty-nine coronary events occurred in the 278 men who performed the exercise test during the following year, whereas only 5 coronary events occurred among the 118 women. The only variable of prognostic importance in women was nontransmural myocardial infarction. In men, the clinical variables increasing age, duration of angina, ST-or T-segment changes on the rest electrocardiogram and increasing angina or nontransmural myocardial infarction as inclusion criteria were associated with increased occurrence of coronary artery bypass surgery, transmural myocardial infarction or cardiac death. Findings of ST-segment depression, limiting chest pain or low rate-pressure product during the exercise test were of greater value than any clinical variable in prediction of coronary artery bypass surgery, transmural myocardial infarction or cardiac death. Within all clinical subgroups of men, the results of the exercise test had an additive predictive value for future coronary events. Combinations of clinical data and exercise test results enabled the best identification of patients with high or low risk for coronary events. (Am J Cardiol 1987;59:208-214) P atients admitted to the coronary care unit because of chest pain but without development of an acute transmural myocardial infarction have an uncertain prognosis. Some of these patients have unstable coronary artery disease [CAD), that is, angina pectoris of recent onset, deterioration of formerly stable (effort-induced) angina or nontransmural myocardial infarctionl-3; others have a less threatening cause of chest pain. Thus, some patients with chest pain in whom unstable CAD is suspected have large areas of j eopardized myocardiurn and probably a high risk of complications,1Js4-7 whereas others have a large coronary flow reserve
Journal of Nuclear Medicine, 2000
he long-termprognosis for patients with acute myocar dial infarction (AMI) has been predicted by exercise electro cardiography, exercise radionuclide angiocardiography, and exercise myocardial scintigraphy (1â€"11). In particular, the left ventricular ejection fraction (LVEF) at rest and at maximum exercise is a useful index for risk assessment or estimation of prognosis after AMI (5â€"11). However, most previous exercise radionuclide angiocardiography studies focusing on long-term prognosis were performed before the eraof reperfusiontherapy.Thrombolysis,by the intravenous or intracoronaryadministrationof urokinaseor tissue plas minogen activator, and direct percutaneous transluminal coronary angioplasty (PTCA) are currently used as reperfu sion therapy in the setting of AM! (12â€"20).Recently, intracoronary stent implantation has also been used to treat AMI (21). The lower peak LVEF value during exercise radionuclide angiocardiography before hospital discharge has been reportedto be a useful predictorof futurecardiac events in patients with AMI who underwent thromboly sis (9). However, it has also been reported that the peak LVEF cannot be used as an index of prognosis (10).