P860Adding clinical risk scores to troponin-based rule-out algorithms improves identification of patients at high risk for coronary revascularization within 6 weeks: the WESTCOR study

• Published in: European heart journal Vol. 40; no. Supplement_1
• Main Authors: Steiro, O, Tjora, H, Langorgen, J, Omland, T, Bjorneklett, R, Nygard, O, Renstrom, R, Skadberg, O, Bonarjee, V, Lindahl, B, Vikenes, K, Aakre, K
• Format: Journal Article
• Language: English
• Published: Oxford University Press 01.10.2019
• Subjects: Coronary Artery Disease - Diagnostic Methods
• ISSN: 0195-668X; 1522-9645
• DOI: 10.1093/eurheartj/ehz747.0457

Abstract Background The ESC 0/3-h and High-STEACS study algorithms using high-sensitive troponin assays have proven effective in ruling out NSTEMI, but the safety of out-of-hospital follow-up of ruled out patients is disputable. Clinical risk scores may help to identify patients who develop major adverse cardiac events (MACE) defined as NSTEMI, death or coronary lesions in need of acute or elective revascularization within six weeks after admittance. Purpose Assess the ability of the ESC and High-STEACS study algorithms alone and in combination with clinical risk scores to identify MACE in unselected patients presenting with chest pain. Methods 985 patients (mean 63 years, 61% male) with suspected NSTE-ACS were consecutively included from Sept. 2015 to Feb. 2017. Serum samples were collected at 0, 3 and 8–12 hours and hs-cTnT and hs-cTnI were measured. The final diagnosis was adjudicated by two independent cardiologists. The troponin-based algorithms where compared to nine clinical risk scores, HEART, CARE, GRACE, T-MACS, TIMI, EDACS, sEDACS, Goldman and Geleijnse. Results The prevalence of NSTEMI during index hospitalization was 13%. The ESC 0/3-h and High-STEACS algorithms missed 3 events of NSTEMI with excellent NPV of 99.5 and 99.6. Rule-out patients with normal ECGs, GRACE score <140 and no residual pain had a prevalence of MACE within 6 weeks of 9% using both algorithms. The most frequent event was non-acute revascularization due to unstable angina pectoris. Three of ten clinical risk scores had higher accuracy than the ESC 0/3-h algorithm for identification of MACE: HEART (AUC 0.84), CARE (AUC 0.79) and T-MACS (AUC 0.76). Combining the ESC 0/3-h rule-out algorithm and HEART≤3 had the best AUC of 0.85, missing only 12 (3%) MACE. Troponin-based algorithms and HEART True pos. True neg. False pos. False neg. NPV PPV Sens. Spes. Prop. low-risk AUC Troponin-based algorithms, endpoint NSTEMI ESC 0/3h TnT 118 628 196 3 99.5 37.6 97.5 76.2 66.8 0.87 High-STEACS TnI 118 715 109 3 99.6 52.0 97.5 86.8 76.0 0.92 Troponin-based algorithms, endpoint MACE ESC 0/3h TnT 143 577 171 54 91.4 45.5 72.6 77.1 66.8 0.75 High-STEACS TnI 130 651 97 67 90.7 57.3 66.0 87.0 76.0 0.77 Troponin-based algorithms combined with HEART score, endpoint MACE ESC 0/3h HEART 3 185 414 334 12 97.2 35.7 94.1 55.4 44.6 0.85 High-STEACS HEART 3 186 411 337 11 97.4 35.6 94.7 55.0 44.7 0.85 Causes of MACE Conclusion The ESC 0/3-h and High-STEACS algorithms identify almost all patients with low risk of NSTEMI, who are candidates for none or out-of-hospital follow-up. However, 9% of ruled out patients have MACE within 6 weeks. The combination of ESC algorithm and clinical risk scores markedly reduce the number of ruled out patients with MACE.