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Chest Pain Scores Compete Head-to-Head

February 16, 2017

Short Attention Span Summary

Of scoring systems for low risk chest pain: unstructured clinical impression of risk, HEART≤3, TIMI = 0, GRACE ≤ 50, and EDACS ≤ 15 (all with a negative non-high sensitivity troponin x 2), only physician gestalt and TIMI had no subsequent missed acute MI (AMI) during the index hospitalization.  This caveat, the number of patients with AMI was only 80, so the 95% CI are a bit wide.  Also, they didn’t follow up after the index visit, so we don’t know about longer-term major adverse coronary events (MACE).  Interestingly, HEART was not as good in this study as in prior validation studies.

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Unstructured physician gestalt of “low risk” or a TIMI score of zero and 2 negative standard troponin assays resulted in zero patients with missed AMI during the index visit to the ED for chest pain.  Before I feel too cavalier about my “gestalting” skills – although the AMI miss rate was zero, the upper 95% CI limit was 3.9%.  Also, this study would have been much stronger if we knew 30-day outcomes for MACE were also zero.

You need a smart friend to walk you through these clinical decision rules, a friend like Amal Mattu!  Evidence Care is a free clinical decision support tool, with EM rock-star authors like Mattu, Kline, and Edlow, that walks you step by step through the evidence to help you navigate tough clinical problems like low risk chest pain and PE.  Mattu wrote the low risk chest pain module.  I like it a lot.


Am J Emerg Med. 2017 Jan 5. pii: S0735-6757(17)30003-7. doi: 10.1016/j.ajem.2017.01.003. [Epub ahead of print]

Missed myocardial infarctions in ED patients prospectively categorized as low risk by established risk scores.

Singer AJ1, Than MP2, Smith S3, McCullough P4, Barrett TW5, Birkhahn R6, Reed M7, Thode HC8, Arnold WD9, Daniels LB10, de Filippi C11, Headden G12, Peacock WF13.

Author information:

1Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, United States. Electronic address: adam.singer@stonybrook.edu.

2Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand.

3Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN, United States.

4Department of Cardiology, Baylor University Medical Center, Dallas, TX, United States.

5Department of Emergency Medicine, Vanderbilt University, Nashville, TN, United States.

6Department of Emergency Medicine, Methodist Hospital, New York, NY, United States.

7International Heart Institute of Montana, Missoula, MT, United States.

8Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, United States.

9Alere, San Diego, CA, United States.

10Department of Medicine, Division of Cardiology, University of California San Diego, La Jolla, CA, United States.

11Department of Emergency Medicine, University of Maryland, Baltimore, MD, United States.

12Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC, United States.

13Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, United States.



Few studies have prospectively compared multiple cardiac risk prediction scores. We compared the rate of missed acute myocardial infarction (AMI) in chest pain patients prospectively categorized as low risk by unstructured clinical impression, and by HEART, TIMI, GRACE, and EDACS scores, in combination with two negative contemporary cardiac troponins (cTn) available in the U.S.


We enrolled 434 patients with chest pain presenting to one of seven emergency departments (ED). Risk scores were prospectively calculated and included the first two cTn. Low risk was defined for each score as HEART≤3, TIMI≤0, GRACE≤50, and EDACS≤15. AMI incidence was calculated for low risk patients and compared across scores using Χ2 tests and C statistics.


The patients’ median age was 57, 58% were male, 60% white, and 80 (18%) had AMI. The missed AMI rate in low risk patients for each of the scores when combined with 2 cTn were HEART 3.6%, TIMI 0%, GRACE 6.3%, EDACS 0.9%, and unstructured clinical impression 0%. The C-statistic was greatest for the EDACS score, 0.94 (95% CI, 0.92-0.97).


Using their recommended cutpoints and non high sensitivity cTn, TIMI and unstructured clinical impression were the only scores with no missed cases of AMI. Using lower cutpoints (GRACE≤48, TIMI=0, EDACS≤11, HEART≤2) missed no case of AMI, but classified less patients as low-risk.

Copyright © 2017 Elsevier Inc. All rights reserved.

PMID: 28108220 [PubMed – as supplied by publisher]

2 thoughts on “Chest Pain Scores Compete Head-to-Head

  • This was a poor study unfortunately I don’t think it adds anything to current literature. Lots of missing data and outcome studied was diagnosis of AMI by committee not hard clinical outcomes. I just hope this study doesn’t stay people back in the direction of admitting all low risk chest pain.

    • It would have been much better had they enrolled more patients and done the standard 30-day follow up for MACE. I don’t think I will change practice. But it did cautiously increase confidence in my clinical assessment with the aid of 2 negative troponins.

What are your thoughts?