Comparison of Various Clinical Risk Assessment Tools in Predicting Major Adverse Cardiac Events in Patients Presenting in Emergency Department with Undifferentiated Cardiac Chest Pain

Article Information

Title: Comparison of Various Clinical Risk Assessment Tools in Predicting Major Adverse Cardiac Events in Patients Presenting in Emergency Department with Undifferentiated Cardiac Chest Pain

Authors: Karim Bakhsh, Tamkeen Pervez, Muhammad Nadeem Ashraf, Muhammad Hamza Rizwan, Nayab Chaudhary, Muhammad Saddam Hussain

Journal: Pakistan Armed Forces Medical Journal (PAFMJ)

HEC Recognition History

Category	From	To
Y	2024-10-01	2025-12-31
Y	2023-07-01	2024-09-30
Y	2021-07-01	2022-06-30
Y	2020-07-01	2021-06-30
Y	1900-01-01	2005-06-30

Publisher: Army Medical College, Rawalpindi.

Country: Pakistan

Year: 2023

Volume: 73

Issue: 1

Language: English

DOI: 10.51253/pafmj.v73i1.8602

Keywords: HEART ScoreGRACE scoreMajor adverse cardiac event (MACE)TIMI score

Abstract

Objective: To compare the “HEART (History, ECG, Age, Risk factors, Troponin), GRACE (Global Registry of Acute Coronary Events), and TIMI (Thrombolysis in Myocardial Infarction)” scores in predicting major adverse cardiac events (MACE) in patients reporting with undifferentiated cardiac chest pain to the Emergency Department (ED).
Study Design: Cross-sectional validation study
Duration and place of Study: Emergency Department, Combined Military Hospital, Rawalpindi Pakistan, from Jan to Jun 2021.
Methodology: Two hundred and thirty-seven adult patients with atraumatic cardiac-like chest pain and non-diagnostic electrocardiogram (ECG) reporting to the ED were included in the study. HEART, GRACE and TIMI scores were calculated from the data. The number of patients with low risk was identified by each score and compared at a fixed safety level of minimum 95% sensitivity. The potential occurrence of MACE was confirmed using a telephonic follow-up six weeks after the presentation.
Results: At an absolute safety level of minimum 95% sensitivity, the HEART score determined 101 patients as “low-risk” with 1.98% MACE missed. The GRACE score identified 49 “low-risk” patients with 4.08% MACE missed, and the TIMI score identified 66 “low-risk” patients with 3.03% MACE missed.
Conclusion: Among the three scores under comparison, the HEART score performed better than the GRACE and TIMI scores at the same safety level and surpassed them in differentiating between those with MACE and without MACE.

Disclaimer: The following sections are produced through an intensive multi-stage analytical pipeline developed by DefinePK, utilizing advanced natural-language processing, domain-specific knowledge models, and automated cross-referencing systems. Despite the rigor and computational effort involved, the generated summary may still contain inaccuracies or incomplete interpretations. Users are strongly advised to verify all critical information against the original paper and its authoritative sources.

Research Objective

To compare the HEART, GRACE, and TIMI scores in predicting major adverse cardiac events (MACE) in patients presenting to the Emergency Department with undifferentiated cardiac chest pain.

Methodology

Cross-sectional validation study conducted in the Emergency Department of Combined Military Hospital, Rawalpindi, Pakistan, from January to June 2021. Two hundred and thirty-seven adult patients with atraumatic cardiac-like chest pain and non-diagnostic electrocardiogram (ECG) were included. HEART, GRACE, and TIMI scores were calculated. The number of patients identified as "low-risk" by each score was compared at a minimum sensitivity of 95%. MACE occurrence was confirmed via telephonic follow-up six weeks post-presentation. Statistical analysis included ROC curves and AUC calculations.

Methodology Flowchart

                        graph TD;
    A["Enroll Patients with Undifferentiated Cardiac Chest Pain & Non-diagnostic ECG"] --> B["Calculate HEART, GRACE, TIMI Scores"];
    B --> C["Identify Low-Risk Patients">= 95% Sensitivity""];
    C --> D["Telephonic Follow-up at 6 Weeks for MACE"];
    D --> E["Analyze ROC Curves and AUCs"];
    E --> F["Compare Score Performance"];
    F --> G["Conclude HEART Score Superiority"];

Discussion

The HEART score performed better than GRACE and TIMI scores in identifying a higher proportion of low-risk patients while missing a minimal number of MACE. This superiority is attributed to the HEART score's design for ED patients with diagnostic uncertainty, whereas GRACE and TIMI were developed for high-risk patients with diagnosed ACS. The HEART score is considered more suitable for undifferentiated chest pain in the ED due to its quick, easy, efficient, and safe application.

Key Findings

At a minimum 95% sensitivity, the HEART score identified 101 patients as "low-risk" with 1.98% MACE missed. The GRACE score identified 49 "low-risk" patients with 4.08% MACE missed, and the TIMI score identified 66 "low-risk" patients with 3.03% MACE missed. The HEART score demonstrated the highest Area Under the Curve (AUC) of 0.76, followed by TIMI (0.66) and GRACE (0.62).

Conclusion

The HEART score is the most effective among the compared tools for identifying low-risk patients with undifferentiated cardiac chest pain in the Emergency Department, demonstrating superior performance in differentiating between patients with and without MACE at the same safety level.

Fact Check

1. Study Duration: The study was conducted from Jan to Jun 2021. (Confirmed in text)
2. Number of MACE: 77 MACEs were developed by 52 (23.0%) patients out of 226 analyzed. (Confirmed in text)
3. HEART Score Low-Risk Patients: The HEART score identified 101 (44.6%) patients as low-risk with 1.98% MACE missed. (Confirmed in text)

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