Journal Article

Performance of risk scores for coronary artery disease: a retrospective cohort study of patients with chest pain in urgent primary care

Smits, Iris, Kleton, Michelle, Lucassen, Wim A M, Manten, Amy, Rietveld, Remco, Harskamp, Ralf E

2021

Overview

ObjectiveTo evaluate the diagnostic performance of the Marburg Heart Score (MHS), INTERCHEST, Gencer rule, Bruins Slot rule and compare these with unaided clinical judgement in patients with chest pain in urgent primary care.DesignRetrospective, cohort study.SettingRegional primary care facility responsible for out-of-hours primary care for a quarter-million people in the Netherlands.ParticipantsConsecutive patients aged ≥18 years who were evaluated for chest pain.Main outcome measuresDiscriminatory ability (C-statistic), sensitivity, specificity, positive and negative predictive values (PPV/NPV). The reference standard involved a composite endpoint of the occurrence of death, acute coronary syndrome or coronary revascularisation (=major adverse cardiac events; MACE) up to 6 weeks after initial contact.ResultsA total of 664 patients were included, of whom 4.8% (n=32) had a MACE event. C-statistics for MHS, INTERCHEST, Gencer and Bruins Slot rule were: 0.77 (95% CI 0.69 to 0.84), 0.85 (95% CI 0.78 to 0.92), 0.72 (95% CI 0.63 to 0.81) and 0.72 (95% CI 0.63 to 0.81), respectively. Optimal diagnostic accuracy was found for MHS ≥2 (sensitivity=81.3%, specificity=67.1%, PPV=11.1%, NPV=98.6%), INTERCHEST ≥2 (sensitivity=87.5%, specificity=78.8%, PPV=17.3%, NPV=99.1%), Gencer ≥2 (sensitivity=84.4%, specificity=37.8%, PPV=6.4%, NPV=98.0%) and Bruins Slot≥2 (sensitivity=90.6%, specificity=40.8%, PPV=7.2%, NPV=98.9%). Physicians referred 157 patients (23.6%) and missed 6 out of 32 MACEs (sensitivity=81.3%, specificity=79.3%, PPV=16.6%, NPV=98.8%). Using INTERCHEST with a referral threshold of ≥2 points, 4 MACEs would have been missed and 162 patients (24.4%) referred. The other risk scores resulted in far higher referral rates.ConclusionWhile available risk scores have reasonable to good discriminatory properties, they do not outperform unaided clinical judgment for evaluating chest pain in urgent primary care. Only the INTERCHEST score may slightly improve risk stratification.

• Publisher: British Medical Journal Publishing Group,BMJ Publishing Group LTD,BMJ Publishing Group
• Subject: Accuracy / Acute Coronary Syndrome - diagnosis / Acute coronary syndromes / Adolescent / Adult / Angina pectoris / Angioplasty / Cardiovascular disease / Chest Pain - diagnosis / Chest Pain - epidemiology / Chest Pain - etiology / Clinical outcomes / Cohort analysis / Cohort Studies / Coronary Artery Disease - diagnosis / coronary heart disease / Coronary vessels / Data collection / Decision making / Electronic health records / Emergency Service, Hospital / Family physicians / General practice / Family practice / Heart attacks / Heart surgery / Hospitals / Humans / ischaemic heart disease / Ischemia / myocardial infarction / Pain / Patients / Primary care / Primary Health Care / Radiation / Retrospective Studies / Risk Assessment - methods / Risk Factors / Vein & artery diseases