Chest Pain Scores

Kristopher Maday, MS, PA-CProgram Director/Associate Professor

University of Tennessee Health Science CenterPhysician Assistant Program

Why Do We Care?

Walker G. EM News. 2015;37(8):310-32

1 : 1816 1 : 16030hr per week50wk per year

2.5 patients per hour5-10% chest pain patients

Every chest pain patient for 5 years to prevent one bad outcome

The Scores• PURSUIT• TIMI• GRACE• FRISC• HEART• EDACS

PURSUIT Trial• Published in 2000• Aim– Predict 30-day risk of death/AMI in

patients with ACS• Design– 9461 patients– 726 hospitals in 28 countries

Boersma E. Circulation. 2000;101(22):2557-2567

Boersma E. Circulation. 2000;101(22):2557-2567

I will cath you

≥ 20%

Thrombolysis in Myocardial Infarction

• Original Study– Published in 2000– Aim

• Create simple risk score for UA/NSTEMI to predict 14-day risk of all cause mortality, AMI, or need for urgent revascularization

– Design• 7081 patients

– Combined patients from TIMI 11b and ESSENCE trial• International, randomized, double-blind

• Validated in 2006Antman EM. JAMA. 2000;282(7):835-842 Pollack CV. Acad Emerg Med. 2006;13(1):13-18

Antman EM. JAMA. 2000;282(7):835-842

Age ≥ 65

≥ 3 CAD Risk Factors

≥ 2 episodes of severe angina in past 24hr

ASA Use in Past 7 days

Known CAD (≥50% stenosis)

ST changes ≥ 0.5mm on EKG

(+) Cardiac Enzyme

(+) FH of CADHTNHLDDM(+) smoker

I will cath you

≥ 4

Global Registry of Acute Coronary Events

• Original Study– Published in 2006– Aim• Predict 6-month risk of death/AMI in patients

with ACS– Design• 43810 patients• 94 hospitals in 14 countries

• Validated in 2009

Fox KA. BMJ. 2006;333(7578):1091 Elbarouni B. Am Heart J. 2009;158(3):392-299

Fox KA. BMJ. 2006;333(7578):1091 Elbarouni B. Am Heart J. 2009;158(3):392-299

GRACE Score Mortality Risk

0-87 0-2%

88-128 3-10%

129-149 10-20%

150-173 20-30%

174-182 40%

183-190 50%

200-207 70%

208-284 90%

≥ 285 99%

FastRevascularizationinInStabilityin Coronary disease

FRISC Score• 1999 – Original study– Primary Aim• Early vs traditional revacularization in chest

pain patients• 58 Scandanavian hospitals• 2457 patients

• 2005 – Analyzed independent variables– Primary aim• Identification of chest pain patients who

would most benefit from early revascularizationFRISC II Investigators. Lancet. 1999;354:708–715 Lagerqvist B. Heart. 2005;91(8):1047-1052

Age ≥ 70MaleDiabetesPrevious AMIST depressionElevated troponinElevated CRP/IL-6

Lagerqvist B. Heart. 2005;91(8):1047-1052

I will cath you

≥ 3

HEART Pathway• Original Study– Published in 2008– Aim• Develop risk score for chest pain patients

presenting to the ED– Design• 122 patients, single center study

• Validated in 2013

Six AJ. Neth Heart J. 2008;16(6):191-196 Backus BE. Int J Cardiol. 2013;168 (3):2153-2158

Six AJ. Neth Heart J. 2008;16(6):191-196 Rezaie S. REBEL EM Blog. 2014.

EDACS• Published in 2014• Aim– Derive a chest pain score for an

accelerated diagnostic protocol• Design– 1974 patients– 2 hospitals

• Self-validated with additional 608 patients

Than M. Emerg Med Australas. 2014;26(1):34-44

Than M. Emerg Med Australas. 2014;26(1):34-44

Than M. Emerg Med Australas. 2014;26(1):34-44

Low RiskEDACS < 16 AND no ischemia on EKG AND 0/2hr troponin (-)

Not Low RiskEDACS ≥ 16 OR new ischemia on EKG OR 0/2hr troponin (+)

I will cath you

Take Home Points• Risk stratification

•Discharge low risk chest pain

•Use clinical gestalt

Thank You!

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