Development of a Clinical Prediction Rule for 30-Day Cardiac Events in Emergency Department Patients With Chest Pain and Possible Acute Coronary Syndrome

Development of a Clinical Prediction Rule for 30-Day Cardiac Events in Emergency Department Patients With Chest Pain and Possible Acute Coronary Syndrome. Hess, E. P., Brison, R. J., Perry, J. J., Calder, L. A., Thiruganasambandamoorthy, V., Agarwal, D., Sadosty, A. T., Silvilotti, M. L., Jaffe, A. S., Montori, V. M., Wells, G. A., & Stiell, I. G. Annals of Emergency Medicine, 59(2):115–125.e1, February, 2012.

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Methods: We prospectively enrolled patients older than 24 years and with a primary complaint of chest pain from 3 academic EDs. Physicians completed standardized data collection forms before diagnostic testing. The primary adjudicated outcome was acute myocardial infarction, revascularization, or death of cardiac or unknown cause within 30 days. We used recursive partitioning to derive the rule and validated the model with 5,000 bootstrap replications. Results: Of 2,718 patients enrolled, 336 (12%) experienced a cardiac event within 30 days (6% acute myocardial infarction, 10% revascularization, 0.2% death). We developed a rule consisting of the absence of 5 predictors: ischemic ECG changes not known to be old, history of coronary artery disease, pain typical for acute coronary syndrome, initial or 6-hour troponin level greater than the 99th percentile, and age greater than 50 years. Patients aged 40 years or younger required only a single troponin evaluation. The rule was 100% sensitive (95% conﬁdence interval 97.2% to 100.0%) and 20.9% speciﬁc (95% conﬁdence interval 16.9% to 24.9%) for a cardiac event within 30 days. Conclusion: This clinical prediction rule identiﬁes ED chest pain patients at very low risk for a cardiac event who may be suitable for discharge. A prospective multicenter study is needed to validate the rule and determine its effect on practice. [Ann Emerg Med. 2012;59:115-125.]

@article{hess_development_2012,
	title = {Development of a {Clinical} {Prediction} {Rule} for 30-{Day} {Cardiac} {Events} in {Emergency} {Department} {Patients} {With} {Chest} {Pain} and {Possible} {Acute} {Coronary} {Syndrome}},
	volume = {59},
	issn = {01960644},
	url = {http://linkinghub.elsevier.com/retrieve/pii/S0196064411013436},
	doi = {10.1016/j.annemergmed.2011.07.026},
	abstract = {Methods: We prospectively enrolled patients older than 24 years and with a primary complaint of chest pain from 3 academic EDs. Physicians completed standardized data collection forms before diagnostic testing. The primary adjudicated outcome was acute myocardial infarction, revascularization, or death of cardiac or unknown cause within 30 days. We used recursive partitioning to derive the rule and validated the model with 5,000 bootstrap replications.
Results: Of 2,718 patients enrolled, 336 (12\%) experienced a cardiac event within 30 days (6\% acute myocardial infarction, 10\% revascularization, 0.2\% death). We developed a rule consisting of the absence of 5 predictors: ischemic ECG changes not known to be old, history of coronary artery disease, pain typical for acute coronary syndrome, initial or 6-hour troponin level greater than the 99th percentile, and age greater than 50 years. Patients aged 40 years or younger required only a single troponin evaluation. The rule was 100\% sensitive (95\% conﬁdence interval 97.2\% to 100.0\%) and 20.9\% speciﬁc (95\% conﬁdence interval 16.9\% to 24.9\%) for a cardiac event within 30 days.
Conclusion: This clinical prediction rule identiﬁes ED chest pain patients at very low risk for a cardiac event who may be suitable for discharge. A prospective multicenter study is needed to validate the rule and determine its effect on practice. [Ann Emerg Med. 2012;59:115-125.]},
	language = {en},
	number = {2},
	urldate = {2018-03-17TZ},
	journal = {Annals of Emergency Medicine},
	author = {Hess, Erik P. and Brison, Robert J. and Perry, Jeffrey J. and Calder, Lisa A. and Thiruganasambandamoorthy, Venkatesh and Agarwal, Dipti and Sadosty, Annie T. and Silvilotti, Marco L.A. and Jaffe, Allan S. and Montori, Victor M. and Wells, George A. and Stiell, Ian G.},
	month = feb,
	year = {2012},
	keywords = {\_tablet},
	pages = {115--125.e1}
}

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Results: Of 2,718 patients enrolled, 336 (12%) experienced a cardiac event within 30 days (6% acute myocardial infarction, 10% revascularization, 0.2% death). We developed a rule consisting of the absence of 5 predictors: ischemic ECG changes not known to be old, history of coronary artery disease, pain typical for acute coronary syndrome, initial or 6-hour troponin level greater than the 99th percentile, and age greater than 50 years. Patients aged 40 years or younger required only a single troponin evaluation. The rule was 100% sensitive (95% conﬁdence interval 97.2% to 100.0%) and 20.9% speciﬁc (95% conﬁdence interval 16.9% to 24.9%) for a cardiac event within 30 days. Conclusion: This clinical prediction rule identiﬁes ED chest pain patients at very low risk for a cardiac event who may be suitable for discharge. A prospective multicenter study is needed to validate the rule and determine its effect on practice. 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