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Dr BE Backus
UMC Utrecht, The Netherlands
Background
� Yearly millions of chest pain patients worldwide
� Only 20% suffers an ACS, but 80% of patients are
admitted for further diagnostics
� Guidelines suggest the use of risk scores to
identify low risk and high risk patients
Ideal risk score is applicable to all chest pain patients
Background
� Guidelines suggest the use of a risk score to calculatethe individual risk of a patiënt
� The long-term risk of patients with NSTEMI is more severe than that of STEMI patients
� Guidelines are written for NSTEMI patients, not chestpain
Audience response question� Would you use a risk score to estimate the ischaemic
risk in patients with chest pain?
1. No
2. HEART
3. TIMI
4. GRACE
5. Other score
Two clinical cases� Patient 1: Male, 47 years old, two episodes of chest pain
with radiation, initiated by physical activity, last episode this morning, smoker, + fam hist. RR 137/68, HR 68, creatinin 73 µmol/L, troponin 0.019
� Patient 2: Male 78 years old, one episode of chest pain, duration of 5-10 minutes, no radiation, known withhypertension. RR 157/89, HR 73, creatinin 86 µmol/L, troponin <0.014
ECG of both cases
Patient 1, 47 year old male
� Patient 2, 78 year old male
Audience response question� According to your clinical view the probability for an
acute coronary syndrome is:
1. Equal for both patients
2. Higher for patient 1 than for patient 2
3. Higher for patient 2 than for patient 1
Audience response question� According to the risk scores, the probability of in-
hospital death in these patients is:
1. Equal for both patients
2. Higher for patient 1 than for patient 2
3. Higher for patient 2 than for patient 1
Risk scores� HEART
� TIMI
� GRACE
� PURSUIT
� SRI
� Others….
http://www.outcomes-umassmed.org/grace/acs_risk/acs_risk_content.html
Patient 1, score 73
Patient 2, score 115
TIMI score
Source: http://www.timi.org/
Patient 1, score 2
Patient 2, score 1
HEART scoreHistory (anamnesis)
Highly suspicious 2
2Moderately suspicious 1
Slightly or non-suspicious 0
ECG Significant ST-deviation 2
1Non specific rep disturbance / LBTB / PM
1
Normal 0
Age ≥ 65 year 2
145 – 65 year 1
≤ 45 year 0
Riskfactors
≥ 3 risk factors or treated atherosclerosis
2
11 or 2 risk factors 1
No risk factors known 0
Troponin ≥ 3x normal limit 2
11-3x normal limit 1
≤ normal limit 0
Total6
History (anamnesis)
Highly suspicious 2
0Moderately suspicious 1
Slightly or non-suspicious 0
ECG Significant ST-deviation 2
0Non specific rep disturbance / LBTB / PM
1
Normal 0
Age ≥ 65 year 2
245 – 65 year 1
≤ 45 year 0
Riskfactors
≥ 3 risk factors or treated atherosclerosis
2
11 or 2 risk factors 1
No risk factors known 0
Troponin ≥ 3x normal limit 2
01-3x normal limit 1
≤ normal limit 0
Total3
Patient 1, score 6 Patient 2, score 3
Probability of death / ACS� Patient 1:
� GRACE score 73 risk of death 0.2% ACS 8%
� TIMI score 2 risk of death 3% ACS 13%
� HEART score 6 risk of death 1.3% ACS 30%
� Patient 2:
� GRACE score 115 risk of death 1% ACS 24%
� TIMI score 1 risk of death 3% ACS 4%
� HEART score 3 risk of death 0.05% ACS 2.5%
Discrepancy in risk scores
� GRACE score totally neglects patients’ history
� GRACE is strongely driven by age
� The older the patient, the more likely he is to die
� TIMI was designed for ACS patients, not chest pain
� HEART is the first score that was meant for patientswith chest pain at the emergency department
� Closely follows clinical reasoning
History (anamnesis)
Highly suspicious 2
Moderately suspicious 1
Slightly or non-suspicious 0
ECG Significant ST-deviation 2
Non specific rep disturbance / LBTB / PM 1
Normal 0
Age ≥ 65 year 2
45 – 65 year 1
≤ 45 year 0
Risk
factors
≥ 3 risk factors or treated atherosclerosis 2
1 or 2 risk factors 1
No risk factors known 0
Troponin ≥ 3x normal limit 2
1-3x normal limit 1
≤ normal limit 0
Total
HEART score chest pain patients
Validation program of HEART
� Two retrospective studies (n=120 + n=880)
� Two prospective studies (n=2388 + n= )
� Several substudies
� Comparison of HEART / TIMI / GRACE score
� HEART in woman / elderly / diabetics
� Medical consumption / cost-effectiveness
� Value of exercise ECG
� Regression analysis
� Value of second troponin
Graphic results of prospective study(n=2388)
0
10
20
30
40
50
60
70
80
Perc
en
tag
e M
AC
E
From minimum to maximum score
HEART
TIMI
GRACE
No MACE MACE p value c-index
HEART 4.0 +/- 2.0 6.5 +/- 1.7 < 0.0001 0.83
TIMI 2.2 +/- 1.6 3.7 +/- 1.4 < 0.0001 0.75
GRACE 95.5 +/- 35 121.2 +/- 34 < 0.0001 0.70
HEART-TIMI-GRACEDiscriminative performance (n=2388)
Risk groups and proposed policy when
using the HEART score (n=6174)
HEART ~ % pts MACE/n MACE DeathProposed
Policy
0-3 32% 38/1993 1.7% 0.05% Discharge
4-6 51% 413/3136 13% 1.3%Observation,
risk management
7-10 17% 518/1045 50% 2.8%Observation,
treatment, CAG
www.heartscore.nl
Audience response question� Will you observe the patient with chest pain until a
second troponin test is available?
1. No
2. Yes
3. Only if the patient has a high risk
Audience response question� Would you base your decision to treat the patient on:
1. First troponin only
2. Representative troponin only
3. Always two sets of troponin
ESC recommendations for diagnosis
and risk assessment (2)
22
ESC recommendations for diagnosis
and risk assessment (3)
23
HEART and second troponin� HEART score was based and first troponin only,
irrespective of time since onset of complaints
� Regular troponin assay of every participating hospital(troponin T and I, mostly fourth generation)
� What is the additional benefit of the second troponintest?
Clin Chem Lab Med. 2013 Aug 12:1-8. [Epub ahead of print]
The value of clinical and laboratory diagnostics for chest pain patients at the emergencydepartment.
Jellema LJ, Backus BE, Six AJ, Braam R, Groenemeijer B, van der Zaag-Loonen HJ, Tio R, van Suijlen JD.
HEART and second troponin
� Retrospective analysis of prospective study
� 720 patients with chest pain
� 20.4% MACE
� Evaluation of clinic, HEART, first and second troponin
Improvement of HEART with
second troponin� Second troponin test in 437 patients
� 29.7% MACE
� NRI with second troponin was 8%
Conventional or Hs Troponin� Small Dutch study
� Chest pain patients at the emergency department
� Each patient HEART score, conventional plus Hs troponin
� HEART score was based on conventional troponin
� HS troponin identified better those patients with a MACE in the intermediate risk category
� Mainly
• cTnT (4e generation) and HsTnT (Roche Diagnostics)
• HEART Score (conventional cTnT)
• Follow up 30 days for major adverse cardiac event (MACE)
Flow chart study protocol
admission
T2
4-6h
after onset
8-10h
after onset
T3T1
High Sensitive Troponine (T2)
Results
HEART score combined with HS Troponin
identifies patients with / without MACE
HEART Score
MACE NoMACE
<0.014 µg/L
(N=68)
1 – 3
4 – 6
7 - 10
0
3 (14%)
0
49
19
0
≥0.014 µg/L
(N=21)
1 – 3
4 – 6
7 - 10
0
3 (30%)
3 (30%)
0
7
6
• 68 patients (76%) normal HsTnT op T2
• 3 patients (3%) rise of HsTnT abovereference value at T3 (mean rise 31%)
• Al these patients HEART > 4
ResultsHigh Sensitive Troponine at T2 and T3
0.020
0.015
0.010
0.005
0.000
T2 T3
HsTnT 4-6 uur: <0.014
Absolute or relative change of Hs Troponin
� Rechlin et al, Circulation 2011;124: 136-145
� 836 unselected chest pain patients, no STEMI
� Baseline, 1- and 2-hour hs troponin
� Patients with NSTEMI
higher baseline troponin
� What change in troponin
is significant?
31
Absolute and relative cardiac troponin changes according to adjudicated final diagnoses.
Reichlin T et al. Circulation 2011;124:136-145Copyright © American Heart Association
Receiver operating characteristic curves of
1-hour and 2-hour changes.
Reichlin T et al. Circulation 2011;124:136-145Copyright © American Heart Association
• Absolute changes higher diagnostic accuracy
• Change of half the reference value significant
• Independant of the assay
Conclusion� Acute chest pain patients are often not treated by their
risk category
� More clinical risk score(s) might guide the physicianbetter than those based on calculated models
� HEART score very good diagnostic accuracy, withconventional / Hs troponin
� Need for second troponin test needs to be investigated(international HEART implementation study)
Audience response question� Will this presentation change your future management
of patients suggestive of myocardial ischemia?
1. No
2. Yes, more use of any risk score
3. Yes, more use of HEART risk score