Usefulness of Early Exercise Testing and Clinical Risk Score for Prognostic Evaluation in Chest Pain Units Without Preexisting Evidence of Myocardial Ischemia

doi:10.1016/j.amjcard.2005.09.107

The American Journal of Cardiology

Volume 97, Issue 5, 1 March 2006, Pages 633-635

https://doi.org/10.1016/j.amjcard.2005.09.107 Get rights and content

We investigated whether the result of early exercise testing yields prognostic information in addition to that afforded by a clinical risk score in patients who present with chest pain in the emergency department. The study group consisted of 340 patients without preexisting evidence of myocardial ischemia. A clinical risk score was calculated. Primary (mortality or myocardial infarction) and secondary (mortality, myocardial infarction, or rehospitalization due to unstable angina) end points at 1 year were defined. Patients with a positive exercise test result underwent invasive management. Frequencies of primary (7.4% vs 2.1%, p = 0.06) and secondary (9.3% vs 2.8%, p = 0.04) end points and risk score (1.6 ± 1.0 vs 1.0 ± 0.9 points, p = 0.0001) were higher in patients with a positive exercise test result. However, in multivariate analysis, clinical risk score was the only independent predictor for the primary (hazard ratio 2.0, 95% confidence interval 1.2 to 3.2, p = 0.004) and secondary (hazard ratio 1.9, 95% confidence interval 1.2 to 2.9, p = 0.003) end points. In conclusion, if a policy of invasive management is implemented for patients with positive exercise test results, the clinical risk score constitutes the main prognostic predictor of 1-year outcome.

References (20)

J. Sanchis et al.
Predictors of short-term outcome in acute chest pain without ST-segment elevation
Int J Cardiol
(2003)
J. Sanchis et al.
Emergency room risk stratification of patients with chest pain without ST-segment elevation
Rev Esp Cardiol
(2003)
J. Sanchis et al.
New risk score for patients with acute chest pain, non–ST-segment deviation and normal troponin concentrationsa comparison with the TIMI risk score
J Am Coll Cardiol
(2005)
V. Bodí et al.
Multimarker risk strategy for predicting 1-month and 1-year major events in non–ST-elevation acute coronary syndromes
Am Heart J
(2005)
W.R. Lewis et al.
Utility and safety of immediate exercise testing of low-risk patients admitted to the hospital for suspected acute myocardial infarction
Am J Cardiol
(1994)
J.D. Kirk et al.
Evaluation of chest pain in low-risk patients presenting to the emergency departmentthe role of immediate exercise testing
Ann Emerg Med
(1998)
W.R. Lewis et al.
Immediate exercise testing of low risk patients with known coronary artery disease presenting to the emergency department with chest pain
J Am Coll Cardiol
(1999)
D.B. Diercks et al.
Identification of patients at risk by graded exercise testing in an emergency department chest pain center
Am J Cardiol
(2000)
C.R. DeFilippi et al.
Randomized comparison of a strategy of predischarge coronary angiography versus exercise testing in low-risk patients in a chest pain-unitin-hospital and long-term outcomes
J Am Coll Cardiol
(2001)
E.A. Amsterdam et al.
Immediate exercise testing to evaluate low-risk patients presenting to the emergency department with chest pain
J Am Coll Cardiol
(2002)

There are more references available in the full text version of this article.

Cited by (23)

External validation of new risk prediction models is infrequent and reveals worse prognostic discrimination
2015, Journal of Clinical Epidemiology
Citation Excerpt :
Of the 127 risk prediction models, 95 (75%) had no subsequently published external validation study [S1–S66] (Table 1/Appendix on the journals website at www.jclinepi.com). Of the remaining 32 models [12–37] (Table 2/Appendix on the journals website at www.jclinepi.com), 10 models [12,15,16,19,23,37] had been validated in subsequent publications only by overlapping author(s) [38–42], 16 models [13,17,18,20,24–33,36] only by different authors [43–57], and only 6 models [14,21–23,34,35] had subsequent validation publications by both overlapping [58–63] and different authors [64–69] (Table 3/Appendix on the journals website at www.jclinepi.com). Derivation studies with or without subsequent validation(s) were published between 1973 and 2010 (median 2007; Table 1, Tables 1 and 2/Appendix on the journals website at www.jclinepi.com).
To evaluate how often newly developed risk prediction models undergo external validation and how well they perform in such validations.
We reviewed derivation studies of newly proposed risk models and their subsequent external validations. Study characteristics, outcome(s), and models' discriminatory performance [area under the curve, (AUC)] in derivation and validation studies were extracted. We estimated the probability of having a validation, change in discriminatory performance with more stringent external validation by overlapping or different authors compared to the derivation estimates.
We evaluated 127 new prediction models. Of those, for 32 models (25%), at least an external validation study was identified; in 22 models (17%), the validation had been done by entirely different authors. The probability of having an external validation by different authors within 5 years was 16%. AUC estimates significantly decreased during external validation vs. the derivation study [median AUC change: −0.05 (P < 0.001) overall; −0.04 (P = 0.009) for validation by overlapping authors; −0.05 (P < 0.001) for validation by different authors]. On external validation, AUC decreased by at least 0.03 in 19 models and never increased by at least 0.03 (P < 0.001).
External independent validation of predictive models in different studies is uncommon. Predictive performance may worsen substantially on external validation.
N-terminal pro-brain natriuretic peptide and high-sensitivity troponin in the evaluation of acute chest pain of uncertain etiology. A PITAGORAS substudy
2013, Revista Espanola de Cardiologia
La troponina ultrasensible ha mejorado el diagnóstico del síndrome coronario agudo en los pacientes que se presentan con dolor torácico y troponina convencional normal. Nuestro objetivo es analizar si la fracción aminoterminal del propéptido natriurético cerebral aporta información adicional.
Se estudió a 398 pacientes, incluidos en el estudio PITAGORAS, que acudieron a urgencias por dolor torácico con troponina convencional normal en dos muestras seriadas (a la llegada y a las 6-8 h). Se midió de forma centralizada la troponina T ultrasensible en las dos muestras y la fracción aminoterminal del propéptido natriurético cerebral en la segunda. Los objetivos fueron diagnóstico de síndrome coronario agudo y evento compuesto de revascularización o evento cardiaco a los 30 días.
Se diagnosticó síndrome coronario agudo a 79 pacientes (20%), y 59 (15%) presentaron el evento compuesto. A superior cuartil de la fracción aminoterminal del propéptido natriurético cerebral se incrementan las frecuencias de diagnóstico de síndrome coronario agudo (el 12, el 16, el 23 y el 29%; p = 0,01) y del evento compuesto (el 6, el 13, el 16 y el 24%; p = 0,004). La elevación de la fracción aminoterminal del propéptido natriurético cerebral (> 125 ng/l) se asoció con ambos objetivos (riesgo relativo = 2,0; intervalo de confianza del 95%, 1,2-3,3; p = 0,02; riesgo relativo = 2,4; intervalo de confianza del 95%, 1,4-4,2; p = 0,004). Sin embargo, en los modelos multivariables ajustados por datos clínicos y el electrocardiograma, la troponina T ultrasensible mostró valor predictivo, pero no la fracción aminoterminal del propéptido natriurético cerebral.
En el dolor torácico de origen incierto y bajo riesgo evaluado mediante troponina T ultrasensible, la fracción aminoterminal del propéptido natriurético cerebral carece de valor predictivo adicional para el diagnóstico o el pronóstico a corto plazo.
High-sensitivity troponin assays have improved the diagnosis of acute coronary syndrome in patients presenting with chest pain and normal troponin levels as measured by conventional assays. Our aim was to investigate whether N-terminal pro-brain natriuretic peptide provides additional information to troponin determination in these patients.
A total of 398 patients, included in the PITAGORAS study, presenting to the emergency department with chest pain and normal troponin levels as measured by conventional assay in 2 serial samples (on arrival and 6 h to 8 h later) were studied. The samples were also analyzed in a central laboratory for high-sensitivity troponin T (both samples) and for N-terminal pro-brain natriuretic peptide (second sample). The endpoints were diagnosis of acute coronary syndrome and the composite endpoint of in-hospital revascularization or a 30-day cardiac event.
Acute coronary syndrome was adjudicated to 79 patients (20%) and the composite endpoint to 59 (15%). When the N-terminal pro-brain natriuretic peptide quartile increased, the diagnosis of acute coronary syndrome also increased (12%, 16%, 23% and 29%; P=.01), as did the risk of the composite endpoint (6%, 13%, 16% and 24%; P=.004). N-terminal pro-brain natriuretic peptide elevation (>125 ng/L) was associated with both endpoints (relative risk= 2.0; 95% confidence interval, 1.2-3.3; P=.02; relative risk=2.4; 95% confidence interval, 1.4-4.2; P=.004). However, in the multivariable models adjusted by clinical and electrocardiographic data, a predictive value was found for high-sensitivity T troponin but not for N-terminal pro-brain natriuretic peptide.
In low-risk patients with chest pain of uncertain etiology evaluated using high-sensitivity T troponin, N-terminal pro-brain natriuretic peptide does not contribute additional predictive value to diagnosis or the prediction of short-term outcomes.
Full English text available from: www.revespcardiol.org/en.
Expert system for predicting unstable angina based on Bayesian networks
2013, Expert Systems with Applications
The use of computer-based clinical decision support (CDS) tools is growing significantly in recent years. These tools help reduce waiting lists, minimise patient risks and, at the same time, optimise the cost health resources. In this paper, we present a CDS application that predicts the probability of having unstable angina based on clinical data. Due to the characteristics of the variables (mostly binary) a Bayesian network model was chosen to support the system. Bayesian-network model was constructed using a population of 1164 patients, and subsequently was validated with a population of 103 patients. The validation results, with a negative predictive value (NPV) of 91%, demonstrate its applicability to help clinicians. The final model was implemented as a web application that is currently been validated by clinician specialists.
Usefulness of high-sensitivity troponin T for the evaluation of patients with acute chest pain and no or minimal myocardial damage
2012, American Heart Journal
Citation Excerpt :
However, the negative predictive value of clinical and ECG data is not usually sufficient for decision making. Therefore, a stress test or imaging technique is commonly required to drive their further management.15-17 This implies an important logistic constraint.
Although high-sensitivity troponins allow early diagnosis of acute myocardial infarction, their role for identification of acute coronary syndrome in patients with normal conventional troponin remains unclear.
A total of 446 patients presenting to the emergency department with chest pain and normal troponin (common practice assays) in 2 serial samples were included. Both samples were also centrally analyzed for high-sensitivity troponin T (hs-TnT) (Roche Diagnostics, Basel, Switzerland). Detection (> 3 ng/L) and 99th percentile (≥ 14 ng/L) cutoffs of the maximum hs-TnT levels (hs-TnTmax) were considered. The end points were acute coronary syndrome diagnosis and the composite of in-hospital revascularization or 30-day cardiac events.
Acute coronary syndrome was adjudicated to 84 patients (19%), and 62 (14%) had the composite end point. In univariate setting, hs-TnTmax > 3 ng/L exhibited high sensitivity (87% and 92%, respectively) and negative predictive value (93% and 97%) for both end points, whereas hs-TnTmax ≥ 14 ng/L provided high specificity (90% and 89%), although low positive predictive values (40% and 33%). After adjusting for clinical (pain characteristics and risk factors) and electrocardiographic data, there was a stepped increase of risk across hs-TnTmax categories (≤ 3, > 3 but < 14, and ≥ 14 ng/L) for both end points; however, the discriminative capacity added was marginal (integrated discrimination improvement of 2.6% and 3.5%, respectively).
Clinical and electrocardiographic data remain the most important tools for the evaluation of patients with chest pain and with no or minimal myocardial damage. The main contribution of hs-TnT is the high negative predictive value of undetectable levels (≤ 3 ng/L).
Predicting unfavorable outcome in subjects with diagnosis of chest pain of undifferentiated origin
2012, American Journal of Emergency Medicine
Citation Excerpt :
On the basis of history and clinical evaluation, all subjects were treated according to different diagnostic programs in relation to their clinical risk profile after negative ECG findings and serial troponin assays. Low-risk subjects (<3 coronary low-risk factors [older age [14], smoking, hypertension, cholesterol, family history of CAD, CRF, history of CVD]) were managed according to a short-term observation program (12 hours) and a second-line evaluation test (ETT or 99m Tc myocardial stress scintigraphy or stress echocardiography or coronary angiography) [15-17]. High-risk subjects (presence of diabetes mellitus, CAD, history of CABG, PTA, or history of HF) were observed for a longer period (24 hours) in a short-term observation unit with serial 12-lead electrocardiography and serial troponin assay (at 0, 6, and 12 hours from entry) and chest radiography.
Subjects with chest pain and a negative diagnostic workup constitute a problem for emergency physicians. We tested the usefulness of clinical variables in predicting 30-day and 6-month outcome in subjects with chest pain of undifferentiated origin after a negative workup.
Chest pain of undifferentiated origin was diagnosed by negative first-line (serial electrocardiograms, troponins assays, and 12- to 24-hour observation) and second-line evaluation (echocardiography, exercise tolerance test, stress scintigraphy, stress echocardiography, coronary angiography). Thirty-day and 6-month outcomes were considered unfavorable in the presence of any of the following: death, acute coronary syndrome, need for urgent coronary revascularization. The variables considered for risk stratification were age, sex, smoking, family history of coronary artery disease, presence of hypertension, high cholesterol levels, diabetes, chronic renal failure, cerebral vascular disease, and history of acute coronary syndrome, percutaneous transluminal angioplasty (PTA), coronary artery by pass graft, and heart failure.
Five items (diabetes, chronic renal failure, history of PTA or bypass, history of heart failure) were associated with 30-day unfavorable outcome (31 events/1262 cases; 2.5%). The receiver operating characteristic area of the selected items was 0.726 (95% confidence interval [CI], 0.654-0.798); sensitivity was 90.3% (73.1-95.8) and specificity was 54.8% (52.0-57.6). A similar panel of items (older age, diabetes, chronic renal failure, history of PTA) predicted an unfavorable 6-month outcome (90 subjects [7.1%], with lower accuracy (receiver operating characteristic area, 0.610 [95% CI, 0.594-0.627, P < .05]; sensitivity, 98.9% [95% CI, 93.1–99.6]; specificity, 21.6% [95% CI, 19.4–23.9]).
In subjects with chest pain of undifferentiated origin, the risk of unfavorable outcome cannot be accurately predicted by the selected clinical items.
Identification of very low risk chest pain using clinical data in the emergency department
2011, International Journal of Cardiology
Citation Excerpt :
Non-invasive stress tests via a chest pain unit protocol are the main tools for decision making. Among them, the exercise test is the most widely available [2–5], although stress echocardiography and multi-slice coronary computed tomography constitute promising alternatives [6,7]. The use of non-invasive tests, however, consumes time and increases costs.
Evaluation of chest pain of uncertain origin in the emergency department is a challenge. Chest pain units, involving non-invasive stress testing, have logistic constraints. Our aim was to identify very low risk patients for early discharge using clinical data.
A total of 772 patients were studied. Ischemia in the electrocardiogram, troponin elevation or history of ischemic heart disease, were exclusion criteria. The primary end point was 30 day cardiac events (death, myocardial infarction or revascularization). The secondary end point was 1 year major events (death or myocardial infarction).
The primary and secondary end point rates were 123 (18%) and 31 (4%). Predictive variables for the primary end point were typical chest pain (OR = 1.8, p = 0.007), ≥2 pain episodes in last 24 h (OR = 3.4, p = 0.0001), age ≥ 55 years (OR = 1.8, p = 0.03), male (OR = 2.2, p = 0.001), diabetes (OR = 1.8, p = 0.01) and family history of ischemic heart disease (OR = 2.0, p = 0.02). A very low risk category could be distinguished (< 2 predictors, n = 114) that showed only 3 (2.6%) events at 30 days (all 3 revascularizations), compared with 120 (18%) in the remaining patients (p = 0.0001). The very low risk criteria had 97% negative predictive for 30 day cardiac events. No very low risk patient presented major events at 1 year compared with 31 (4.7%) in the remaining patients (p = 0.009).
In patients presenting to the emergency department with chest pain of uncertain origin and without prior ischemic heart disease, very low risk patients can be identified using clinical data. These patients could be quickly discharged without further non-invasive stress testing.

View all citing articles on Scopus

: This work was supported by a grant from Instituto de Salud Carlos III, Spanish Public Health Care System.

View full text

Coronary artery diseaseUsefulness of Early Exercise Testing and Clinical Risk Score for Prognostic Evaluation in Chest Pain Units Without Preexisting Evidence of Myocardial Ischemia

Int J Cardiol

Rev Esp Cardiol

J Am Coll Cardiol

Am Heart J

Am J Cardiol

Ann Emerg Med

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Coronary artery disease
Usefulness of Early Exercise Testing and Clinical Risk Score for Prognostic Evaluation in Chest Pain Units Without Preexisting Evidence of Myocardial Ischemia