Comparing the utility of clinical risk scores and integrated clinical judgement in patients with suspected acute coronary syndrome - Meier, M.; Boeddinghaus, J.; Nestelberger, T.; Koechlin, L.; Lopez-Ayala, P.; Wussler, D.; Walter, J. E.; Zimmermann, T.; Badertscher, P.; Wildi, K.; Gimenez, M. R.; Puelacher, C.; et al. (Eur Heart J Acute Cardiovasc Care, 2023)
AIMS: The utility of clinical risk scores regarding the prediction of major adverse cardiac events (MACE) is uncertain. We aimed to directly compare the prognostic performance of five established clinical risk scores as well as an unstructured integrated clinical judgement (ICJ) of the treating emergency department (ED) physician. METHODS AND RESULTS: Thirty-day MACE including all-cause death, life-threatening arrhythmia, cardiogenic shock, acute myocardial infarction (including the index event), and unstable angina requiring urgent coronary revascularization were centrally adjudicated by two independent cardiologists in patients presenting to the ED with acute chest discomfort in an international multicentre study. We compared the prognostic performance of the HEART score, GRACE score, T-MACS, TIMI score, and EDACS, as well as the unstructured ICJ of the treating ED physician (visual analogue scale to estimate the probability of acute coronary syndrome, ranging from 0 to 100). Among 4551 eligible patients, 1110/4551 patients (24.4%) had at least one MACE within 30 days. Prognostic accuracy was high and comparable for the HEART score, GRACE score, T-MACS, and ICJ [area under the receiver operating characteristic curve (AUC) 0.85-0.87] but significantly lower and only moderate for the TIMI score (AUC 0.79, P < 0.001) and EDACS (AUC 0.74, P < 0.001), resulting in sensitivities for the rule-out of 30-day MACE of 93-96, 87 (P < 0.001), and 72% (P < 0.001), respectively. CONCLUSION: The HEART score, GRACE score, T-MACS, and unstructured ICJ of the treating physician, not the TIMI score or EDACS, performed well for the prediction of 30-day MACE and may be considered for routine clinical use. TRIAL REGISTRATION: ClinicalTrials.gov number NCT00470587.
Keywords: journalArticle; (P300PB_167803), the Swiss Heart Foundation, the Swiss Society of Cardiology, the; *Acute Coronary Syndrome/diagnosis/complications; Abbott, Amgen, Brahms, Roche, Singulex, and Siemens. C.M. has received research; Akademische Gesellschaft Basel'. M.R.G. received research grants from the Swiss; Akademische Gesellschaft') and from the University of Basel. K.W. received a; B.Braun, Siemens, Beckman Coulter, Bayer, Ortho Clinical Diagnostics, Edwards; BMS, Idorsia, Novartis, Osler, Roche, Sanofi, Siemens, and Singulex. All other; Basel and the Division of Internal Medicine, the Swiss Academy of Medical; Chest Pain/etiology; Clinical Diagnostics, Quidel, Roche, and Siemens. D.M.G. reports grants from the; Clinical Reasoning; Clinical judgement; Coulter, Brahms, Idorsia, Novartis, Ortho Clinical Diagnostics, Quidel, Roche,; Diagnosis of ACS; Diagnostics, and Quidel Corporation. T.N. received research support from the; Emergency Service, Hospital; Foundation and a PhD scholarship from the University of Queensland. C.P. received; Foundation, as well as the 'Freiwillige Akademische Gesellschaft Basel'. J.E.W.; Foundation, the Margarete und Walter Lichtenstein-Stiftung (3MS1038), and the; Gottfried and Julia Bangerter-Rhyner Foundation as well as research grants from; Gottfried and Julia Bangerter-Rhyner Foundation, and the Prince Charles Hospital; Herzschrittmacher und Elektrophysiologie' and the FAG Basel ('Freiwillige; Humans; Lifesciences, and Orion Pharma, outside the submitted work. L.K. received a; National Science Foundation (P400PM_180828), the Swiss Heart Foundation, and the; Paulo, Brazil) and personal fees from Roche, outside the submitted work. R.T.; Prospective Studies; Research Foundation Basel as well as speaker honoraria/consulting honoraria from; Risk Assessment/methods; Risk Factors; Risk scores; Sciences, and the Gottfried and Julia Bangerter-Rhyner-Foundation and speaker; Siemens, Singulex, and Sphingotec as well as speaker honoraria/consulting; Swiss Academy of Medical Sciences, and the Gottfried and Julia Bangerter-Rhyner; Swiss Heart Foundation and FAPESP (Fundacao de Amparo a Pesquisa do Estado de Sao; Swiss National Science Foundation (P400PM_191037/1), the Prof. Dr. Max Cloetta; The manuscript and its content have not been published previously and are not; University Hospital Basel as well as speaker honoraria/consulting honoraria from; University Hospital of Basel, the University of Basel, and the Cardiovascular; Women and Heart Foundation and speaker/consulting honoraria from Abbott, Ortho; access to all of the data in the study and take responsibility for the integrity; approved the manuscript. The sponsors had no role in designing or conducting the; authors declare that they have no conflict of interest with this study. The; being considered for publication elsewhere in whole or in part in any language,; data, vouch for the data and analysis, wrote the paper, and decided to submit it; for publication. J.B., T.N., R.T., L.K., P.B., M.R.G., K.W., and C.M. had full; honoraria from Amgen, Astra Zeneca, Bayer, Beckman Coulter, Boehringer Ingelheim,; honoraria/consulting honoraria from Siemens, Roche Diagnostics, Ortho Clinical; hs-cTn assays investigated were donated by the manufacturers, who had no role in; including publicly accessible websites or e-print servers. We disclose that J.B.; manuscript, or the decision to submit the manuscript for publication; of the data and the accuracy of the data analysis. All authors have read and; received a research grant from the Swiss Academy of Medical Sciences and the; received research grants from the University of Basel, the University Hospital of; received research support from the Swiss National Science Foundation; research grant from the 'Freiwillige Akademische Gesellschaft Basel', the; research grant from the Swiss Heart Foundation, the University of Basel, the; research support from the Swiss Heart Foundation and Roche Diagnostics, outside; study and no role in gathering or analysing the data or writing the manuscript