Classification performance of clinical risk scoring in suspected acute coronary syndrome beyond a rule-out troponin profile

Ehsan Khan; Kristina Lambrakis; Andrew Blyth; Anil Seshadri; Michael J R Edmonds; Tom Briffa; Louise A Cullen; Stephen Quinn; Matthew Horsfall; Erin Morton; John K French; Cynthia Papendick; Adam J Nelson; Derek P Chew

doi:10.1093/ehjacc/zuab040

Classification performance of clinical risk scoring in suspected acute coronary syndrome beyond a rule-out troponin profile

Eur Heart J Acute Cardiovasc Care. 2021 Dec 6;10(9):1038-1047. doi: 10.1093/ehjacc/zuab040.

Authors

Ehsan Khan^{1

2}, Kristina Lambrakis^{1

2}, Andrew Blyth^{1

2}, Anil Seshadri^{1

2}, Michael J R Edmonds², Tom Briffa³, Louise A Cullen^{4

5

6}, Stephen Quinn^{7

8}, Matthew Horsfall^{1

2}, Erin Morton¹, John K French⁹, Cynthia Papendick³, Adam J Nelson^{2

10

11}, Derek P Chew^{1

2

3}

Affiliations

¹ College of Medicine & Public Health, Flinders University, Sturt Road, Bedford Park, SA 5042, Australia.
² South Australian Department of Health, 11 Hindmarsh Square, Adelaide, SA 5000, Australia.
³ School of Population and Global Health, University of Western Australia, Clifton Street, Nedlands, Perth, WA 6009, Australia.
⁴ Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, QLD 4029, Australia.
⁵ School of Public Health, Queensland University of Technology, George Street, Brisbane, QLD 4000, Australia.
⁶ School of Medicine, University of Queensland, St Lucia, Brisbane, QLD 4072, Australia.
⁷ Department of Statistics, Swinburne University of Technology, John Street, Hawthorne, Melbourne, VIC 3122, Australia.
⁸ Department of Health Science and Biostatistics, Swinburne University of Technology, John Street, Hawthorne, Melbourne, VIC 3122, Australia.
⁹ Department of Cardiology, Liverpool Hospital, Elizabeth & Goulburn Street, Liverpool, Sydney, NSW 2170, Australia.
¹⁰ South Australian Health and Medical Research Institute, North Terrace, Adelaide, SA 5000, Australia.
¹¹ School of Medicine, University of Adelaide, North Terrrace, Adelaide, SA 5000, Australia.

PMID: 34195809
DOI: 10.1093/ehjacc/zuab040

Abstract

Aims: High-sensitivity cardiac troponin strategies can provide risk stratification in patients with suspected acute coronary syndrome (ACS) in the emergency department (ED). This study evaluated whether clinical risk scoring improves the classification performance of a rule-out profile in suspected ACS.

Methods and results: Patients presenting to ED with suspected ACS as part of the RAPID-TnT trial randomized to the intervention arm were included. Results ≥5 ng/L were available for all participants in this analysis. We evaluated the Thrombolysis In Myocardial Infarction (TIMI) risk score, History ECG Age Risk factors Troponin (HEART) score, and Emergency Department Assessment of Chest pain Score (EDACS) in addition to a rule-out profile based on the 0/1-h high-sensitivity cardiac troponin T protocol (<5 ng/L or ≤12 ng/L and a change of <3 ng/L at 1-h) using test performance parameters focusing on low-risk groups to identify the primary endpoint (TIMI ≤ 1, HEART ≤ 3, EDACS < 16). Primary endpoint was a composite of type 1/2 myocardial infarction (MI) at index presentation and all-cause mortality or type 1/2 MI at 30 days. A total of 3378 participants were enrolled between August 2015 and April 2019 of which 108 were ineligible/withdrew consent (intervention arm: n = 1638). Sensitivity, specificity, negative predictive value (NPV), and area under the curve (AUC) of the rule-out profile was 94.4%, 76.8%, 99.6%, and 0.86, respectively with 72.9% identified as 'low-risk'. Adding the clinical risk scores did not improve the sensitivity, NPV, or AUC with significantly lower specificity and 'low-risk' classified participants.

Conclusions: Addition of clinical risk scores to rule-out profile did not demonstrate improved classification performance for identifying the composite of type 1/2 MI at index presentation and all-cause mortality or type 1/2 MI at 30 days.

Clinical trials registration: URL: https://www.anzctr.org.au. Reg. No. ACTRN12615001379505.

Keywords: Acute coronary syndromes; Chest pain assessment; Clinical trial; Myocardial infarction; Risk prediction; Troponin.

Publication types

Clinical Trial

MeSH terms

Acute Coronary Syndrome* / diagnosis
Biomarkers
Chest Pain / diagnosis
Chest Pain / etiology
Emergency Service, Hospital
Humans
Myocardial Infarction* / diagnosis
Prospective Studies
Risk Assessment
Troponin
Troponin T

Substances

Biomarkers
Troponin
Troponin T

Abstract

Publication types

MeSH terms

Substances

Grants and funding