Ból w klatce piersiowej – Rokowania, prognozy i postęp choroby

Ból w klatce piersiowej
Rokowania, prognozy i postęp choroby

Ból w klatce piersiowej stanowi istotne wyzwanie diagnostyczne w podstawowej opiece zdrowotnej, gdzie około 2-4% pacjentów z tym objawem zostaje zdiagnozowanych z niestabilną dławicą piersiową lub zawałem mięśnia sercowego. Roczna śmiertelność u pacjentów z bólem niesercopochodnym (NCCP) wynosi 2,3%, a u pacjentów z sercopochodnym (CCP) 7,2% (p<0,001), przy czym częstość poważnych zdarzeń sercowo-naczyniowych (MACE) wynosi odpowiednio 5,1% vs 8,3% (p=0,026). Kluczowe jest stosowanie narzędzi prognostycznych, takich jak skale HEART, TIMI i GRACE, które wykazują dobrą zdolność dyskryminacyjną w ocenie ryzyka MACE i długoterminowej śmiertelności sercowo-naczyniowej (C-statystyka dla GRACE 0,829, TIMI 0,803). W podstawowej opiece zdrowotnej rekomendowane są kliniczne reguły decyzyjne, zwłaszcza Marburg Heart Score z NPV 97,3-98,7%, przewyższający ocenę kliniczną w wykrywaniu choroby wieńcowej. Pacjenci bez rozpoznania przez 6 miesięcy wymagają ścisłego monitorowania ze względu na podwyższone ryzyko MACE przez co najmniej 5 lat.

Prognozy dla pacjentów z bólem w klatce piersiowej

Rokowanie w sercowym i niesercowym bólu w klatce piersiowej
Narzędzia prognostyczne w ocenie ryzyka
Kliniczne reguły decyzyjne w prognozowaniu
Biomarkery i obrazowanie w prognozowaniu
Systemy wspomagania decyzji klinicznych i uczenie maszynowe
Prognozy dla pacjentów poddawanych zabiegom kardiochirurgicznym

Diagnostyka różnicowa i jej wpływ na prognozę
Zalecenia dla praktyki klinicznej
Podsumowanie i perspektywy

Kolejne rozdziały

Prognozy dla pacjentów z bólem w klatce piersiowej

Ból w klatce piersiowej stanowi około 1% wszystkich wizyt w podstawowej opiece zdrowotnej, a 2-4% z tych pacjentów zostanie zdiagnozowanych z niestabilną dławicą piersiową lub zawałem mięśnia sercowego.¹ Prognozowanie wyniku klinicznego u pacjentów z bólem w klatce piersiowej ma kluczowe znaczenie dla optymalizacji postępowania diagnostyczno-terapeutycznego oraz efektywnej alokacji zasobów opieki zdrowotnej.

Rokowanie w sercowym i niesercowym bólu w klatce piersiowej

Badania porównawcze wykazują istotne różnice w rokowaniu między pacjentami z sercopochodnym (CCP) i niesercopochodnym (NCCP) bólem w klatce piersiowej. Roczna śmiertelność z wszystkich przyczyn u pacjentów z NCCP wynosi 2,3% w porównaniu do 7,2% u pacjentów z CCP (p<0,001). Częstość występowania poważnych zdarzeń sercowo-naczyniowych (MACE) w ciągu roku wynosi odpowiednio 5,1% vs 8,3% (p=0,026).² Pomimo lepszego rokowania u pacjentów z NCCP, należy pamiętać, że również w tej grupie istnieje ryzyko wystąpienia MACE, szczególnie u osób z historią choroby wieńcowej (CAD) w wywiadzie.³

Warto zaznaczyć, że pacjenci, u których ból w klatce piersiowej pozostaje bez konkretnej diagnozy przez sześć miesięcy od pierwszej prezentacji, wykazują podwyższone ryzyko zdarzeń sercowo-naczyniowych przez co najmniej pięć lat. Ryzyko to jest znacząco wyższe w porównaniu do pacjentów, którzy otrzymali diagnozę bólu niesercowego.⁴ Co więcej, pacjenci, którzy przeszli diagnostykę kardiologiczną w ciągu pierwszych sześciu miesięcy, wykazują wyższe długoterminowe ryzyko chorób sercowo-naczyniowych niż ci, którzy takiej diagnostyki nie przeszli, niezależnie od ich początkowej diagnozy.⁵

Narzędzia prognostyczne w ocenie ryzyka

Dla skutecznej stratyfikacji ryzyka opracowano kilka narzędzi prognostycznych, które pomagają klinicystom w podejmowaniu decyzji diagnostycznych i terapeutycznych.

Skala HEART jest jednym z najlepszych narzędzi do stratyfikacji ryzyka u pacjentów z bólem w klatce piersiowej. Badania walidacyjne wykazały, że w ciągu 30 dni od wizyty na oddziale ratunkowym zdarzenia MACE wystąpiły u 16,2% pacjentów, przy czym częstość występowania wynosiła 1,2% w grupie niskiego ryzyka, 10,8% w grupie pośredniego ryzyka i 62,4% w grupie wysokiego ryzyka.⁶ Skala HEART wykazuje dobrą zdolność dyskryminacyjną w przewidywaniu wystąpienia MACE w ciągu 30 dni, jednak jej zastosowanie w podejmowaniu decyzji klinicznych powinno być ostrożne.⁷

Skale TIMI i GRACE również wykazują bardzo dobrą dyskryminację dla długoterminowej śmiertelności sercowo-naczyniowej, nawet u pacjentów z bólem w klatce piersiowej z prawidłowym lub niediagnostycznym elektrokardiogramem po wykluczeniu ostrego zespołu wieńcowego (ACS). Dla pacjentów po wykluczeniu ACS, statystyki C wynosiły 0,829 dla skali GRACE i 0,803 dla skali TIMI.⁸ W analizie wieloczynnikowej, znana przewlekła niewydolność serca, stosowanie inhibitorów ACE oraz wynik GRACE były niezależnymi predyktorami śmiertelności sercowo-naczyniowej.⁹

Kliniczne reguły decyzyjne w prognozowaniu

Dla lekarzy podstawowej opieki zdrowotnej opracowano kilka klinicznych reguł decyzyjnych (CDR) do oceny bólu w klatce piersiowej:

Marburg Heart Score (MHS) – najbardziej kompleksowo przetestowana reguła, która przewyższa samą ocenę kliniczną w wykrywaniu choroby wieńcowej. Charakteryzuje się wysoką czułością i akceptowalną swoistością, z ujemną wartością predykcyjną (NPV) 97,3-98,7% w wielu badaniach prospektywnych.¹⁰¹¹
INTERCHEST – zwalidowana reguła decyzyjna, która może przewidzieć obecność lub brak CAD u pacjentów prezentujących ból w klatce piersiowej w warunkach podstawowej opieki zdrowotnej.¹²
Reguła Gencera – służy do wykluczania stabilnej CAD.¹³
Reguła Grijseelsa (NPV 82,4%, PPV 56,9%) i reguła Bruins Slot (NPV 91,7%, PPV 23,4%) – służą do wykluczania ACS, jednak obecnie nie osiągają wystarczających parametrów do bezpiecznego wykluczania ACS w warunkach podstawowej opieki zdrowotnej.¹⁴
Vancouver Chest Pain Rule – reguła identyfikująca pacjentów z bardzo niskim ryzykiem, którzy mogą być bezpiecznie wypisani po krótkim pobycie na oddziale ratunkowym. Zgodnie z tą regułą, pacjenci mają bardzo niskie ryzyko ostrego zespołu wieńcowego, jeśli mają prawidłowy początkowy EKG, brak wcześniejszego niedokrwiennego bólu w klatce piersiowej i wiek poniżej 40 lat. W badaniu derywacyjnym reguła ta wykazała czułość 98,8% i swoistość 32,5%.¹⁵¹⁶

Biomarkery i obrazowanie w prognozowaniu

Oprócz klasycznych skal ryzyka, coraz większe znaczenie w prognozowaniu wyników u pacjentów z bólem w klatce piersiowej mają biomarkery i zaawansowane techniki obrazowania.

MikroRNA-1 (miR-1) jest obiecującym biomarkerem, który może pomóc w diagnostyce wczesnego zawału mięśnia sercowego (AMI) i przewidywaniu rokowania u pacjentów z bólem w klatce piersiowej. Badania wskazują, że dokładność diagnostyczna może być podwyższona, gdy miR-1 jest łączony z troponinami sercowymi (cTnI). Chociaż nie wykazano statystycznie istotnej zdolności miR-1 do przewidywania przyszłego AMI, może on prognozować śmiertelność w ciągu 720 dni u pacjentów z bólem w klatce piersiowej.¹⁷

W zakresie obrazowania, badania sugerują, że obrazowanie dla wywołanego niedokrwienia mięśnia sercowego poprzez echokardiografię obciążeniową (DSE) i scyntygrafię perfuzyjną mięśnia sercowego (MPS) nie przewiduje długoterminowej śmiertelności sercowo-naczyniowej u pacjentów z bólem w klatce piersiowej z prawidłowym lub niediagnostycznym elektrokardiogramem po wykluczeniu ACS.¹⁸

Jednak wielomodalne obrazowanie odgrywa kluczową rolę we wczesnej identyfikacji niektórych specyficznych przyczyn bólu w klatce piersiowej, takich jak dziedziczna amyloidoza serca transtyretynowa (hATTR-CA). Wczesna diagnoza i aktywne leczenie mogą znacząco poprawić rokowanie, kontrolować objawy niewydolności serca i poprawić jakość życia u tych pacjentów.¹⁹

Systemy wspomagania decyzji klinicznych i uczenie maszynowe

Nowoczesne systemy wspomagania decyzji klinicznych (CDSS) i techniki uczenia maszynowego mają potencjał do znacznej poprawy prognostyki u pacjentów z bólem w klatce piersiowej.

Model CoDE-ACS oparty na uczeniu maszynowym, uwzględniający stężenia troponiny sercowej, wiek, płeć, choroby współistniejące i czas od wystąpienia objawów, wykazuje doskonałą dyskryminację dla zawału mięśnia sercowego (AUC 0,953; 95% CI 0,947-0,958). Model ten identyfikuje więcej pacjentów przy przyjęciu jako mających niskie prawdopodobieństwo zawału mięśnia sercowego niż stałe progi troponiny sercowej (61% vs 27%) przy podobnej ujemnej wartości predykcyjnej i mniej jako mających wysokie prawdopodobieństwo zawału mięśnia sercowego (10% vs 16%) przy większej dodatniej wartości predykcyjnej.²⁰

Pacjenci zidentyfikowani jako mający niskie prawdopodobieństwo zawału mięśnia sercowego mieli niższy wskaźnik zgonów z przyczyn sercowych niż osoby z pośrednim lub wysokim prawdopodobieństwem po 30 dniach (0,1% vs 0,5% i 1,8%) i po 1 roku (0,3% vs 2,8% i 4,2%; P<0,001 dla obu).²¹ CoDE-ACS stosowany jako system wspomagania decyzji klinicznych ma potencjał do zmniejszenia liczby przyjęć do szpitala i przyniesienia znacznych korzyści dla pacjentów i świadczeniodawców opieki zdrowotnej.²²

Inne zaawansowane techniki uczenia maszynowego również wykazują obiecujące wyniki w przewidywaniu chorób sercowo-naczyniowych. Metody takie jak naiwny klasyfikator Bayesa i sieci neuronowe RBF osiągnęły dokładność 94,78% w prognozowaniu obecności choroby sercowo-naczyniowej wieńcowej. Metoda kwantyzacji wektora uczenia (Learning Vector Quantization) osiągnęła najwyższą dokładność klasyfikacji wynoszącą 98,78%, ze swoistością 97,1% i czułością 97,91%, precyzją 98,07% i wartościami F1-score i F-measure wynoszącymi odpowiednio 95,31% i 97,89%.²³

Prognozy dla pacjentów poddawanych zabiegom kardiochirurgicznym

U pacjentów z bólem w klatce piersiowej spowodowanym zaawansowaną chorobą wieńcową, którzy wymagają interwencji chirurgicznej, prognoza zależy od wielu czynników.

Krótkoterminowa śmiertelność po pomostowaniu tętnic wieńcowych (CABG) zależy od wielu czynników, w tym płci, wieku, chorób współistniejących, czasu trwania krążenia pozaustrojowego (CPB) i pilności operacji.²⁴ Czas CPB i zaklemowania aorty wykazują istotny związek ze śmiertelnością wewnątrzszpitalną (wartości P odpowiednio 0,000 i 0,05).²⁵

Liczba pomostowanych naczyń również ma istotny związek (P = 0,002) ze śmiertelnością wewnątrzszpitalną – im więcej naczyń pomostowano, tym wyższa śmiertelność wewnątrzszpitalna.²⁶ Powikłania takie jak udar mózgu, zaburzenia rytmu serca i opóźniona ekstubacja mają znaczący wpływ na śmiertelność wewnątrzszpitalną. Sam udar mózgu jest czynnikiem ryzyka śmiertelności, przewidującym 2-krotny wzrost ryzyka śmiertelności w porównaniu z pacjentami bez udaru, co jest szczególnie widoczne w pierwszym roku po operacji.²⁷

Diagnostyka różnicowa i jej wpływ na prognozę

Dokładna diagnostyka różnicowa bólu w klatce piersiowej ma kluczowe znaczenie dla odpowiedniej prognozy i leczenia. Kombinacja wieku, płci i rodzaju bólu w klatce piersiowej może przewidzieć prawdopodobieństwo choroby wieńcowej jako przyczyny bólu w klatce piersiowej.²⁸

Meta-analiza badań oceniających rolę wcześniejszego bólu w klatce piersiowej w diagnozowaniu ACS doszła do wniosku, że ból w klatce piersiowej, który jest opłucnowy, pozycyjny lub odtwarzalny przy palpacji i nie jest związany z wysiłkiem, wiąże się z niskim ryzykiem ACS.²⁹

Zmiany w EKG mogące zwiększać prawdopodobieństwo ACS obejmują uniesienie odcinka ST, nowo powstały blok lewej odnogi pęczka Hisa, obecność załamków Q lub nowe odwrócenia załamka T.³⁰

U pacjentów z bólem w klatce piersiowej niewymagających natychmiastowego skierowania, którzy mają niskie do pośredniego prawdopodobieństwo choroby wieńcowej przed testem, należy rozważyć test wysiłkowy. Ocena za pomocą angiografii tomografii komputerowej tętnic wieńcowych (CCTA) zmniejsza liczbę niezakończonych zgonem ostrych zawałów mięśnia sercowego i jest umiarkowanie dokładniejsza niż EKG wysiłkowe w wykluczaniu CAD u pacjentów z bólem w klatce piersiowej.³¹ Obrazowanie metodą rezonansu magnetycznego serca może być przydatne w ocenie typowej dławicy piersiowej.³²

Zalecenia dla praktyki klinicznej

Na podstawie aktualnych dowodów naukowych, można sformułować następujące zalecenia dla praktyki klinicznej w prognozowaniu wyników u pacjentów z bólem w klatce piersiowej:

Wstępna stratyfikacja ryzyka: Pacjenci z podejrzeniem ACS lub zmianami w EKG powinni być natychmiast transportowani na oddział ratunkowy.³³
Wykorzystanie skal ryzyka: Skale HEART, TIMI i GRACE powinny być rutynowo stosowane do oceny ryzyka u pacjentów z bólem w klatce piersiowej.³⁴³⁵
Diagnostyka w podstawowej opiece zdrowotnej: Marburg Heart Score jest najbardziej wszechstronnie przetestowaną regułą i wydaje się przewyższać samą ocenę kliniczną.³⁶
Monitorowanie pacjentów bez diagnozy: Pacjenci, u których ból w klatce piersiowej pozostaje bez diagnozy przez sześć miesięcy od pierwszej prezentacji, wymagają ścisłego monitorowania ze względu na podwyższone ryzyko zdarzeń sercowo-naczyniowych.³⁷
Zastosowanie zaawansowanych technologii: Systemy wspomagania decyzji klinicznych oparte na uczeniu maszynowym, takie jak CoDE-ACS, powinny być rozważone jako uzupełnienie tradycyjnych metod oceny ryzyka.³⁸³⁹
Badania dodatkowe: U pacjentów z niskim do pośredniego prawdopodobieństwem CAD należy rozważyć test wysiłkowy, CCTA lub obrazowanie metodą rezonansu magnetycznego serca.⁴⁰

Podsumowanie i perspektywy

Prognozowanie wyników u pacjentów z bólem w klatce piersiowej jest złożonym zadaniem wymagającym uwzględnienia wielu czynników klinicznych, biomarkerów i wyników badań obrazowych. Aktualnie dostępne narzędzia prognostyczne, takie jak skale HEART, TIMI i GRACE, oraz kliniczne reguły decyzyjne, takie jak Marburg Heart Score, oferują dobrą dokładność w przewidywaniu ryzyka zdarzeń sercowo-naczyniowych.

Przyszłe badania powinny koncentrować się na roli wdrażania testów markerów sercowych typu point-of-care do klinicznych reguł decyzyjnych dla ostrego bólu w klatce piersiowej, a także na efektywności kosztowej strategii diagnostycznej opartej na Marburg Heart Score dla przerywanego bólu w klatce piersiowej.⁴¹ Ponadto, dalszy rozwój systemów wspomagania decyzji klinicznych opartych na uczeniu maszynowym, takich jak CoDE-ACS, oraz integracja danych klinicznych, genetycznych i obrazowych może prowadzić do jeszcze dokładniejszego prognozowania i personalizacji opieki nad pacjentami z bólem w klatce piersiowej.

Narzędzie prognostyczne	Zastosowanie	Parametry diagnostyczne	Zalety	Ograniczenia
Skala HEART	Stratyfikacja ryzyka MACE w ciągu 30 dni	Dobra dyskryminacja dla MACE w ciągu 30 dni	Prosta w użyciu, dobrze zwalidowana	Wymaga ostrożności w podejmowaniu decyzji klinicznych
Skala TIMI	Przewidywanie długoterminowej śmiertelności sercowo-naczyniowej	C-statystyka 0,803	Dokładny predyktor nawet po wykluczeniu ACS	Mniej specyficzna dla pacjentów z NCCP
Skala GRACE	Przewidywanie długoterminowej śmiertelności sercowo-naczyniowej	C-statystyka 0,829	Niezależny predyktor śmiertelności sercowo-naczyniowej	Wymaga wielu zmiennych do obliczenia
Marburg Heart Score	Wykluczanie CAD u pacjentów z przerywanym bólem w klatce piersiowej	NPV 97,3-98,7%	Przewyższa samą ocenę kliniczną, dobrze przetestowana	Ograniczona do przerywanego bólu w klatce piersiowej
INTERCHEST	Przewidywanie obecności lub braku CAD	Zwalidowana w warunkach podstawowej opieki zdrowotnej	Przydatna w podstawowej opiece zdrowotnej	Mniej danych walidacyjnych niż MHS
Vancouver Chest Pain Rule	Identyfikacja pacjentów o bardzo niskim ryzyku ACS	Czułość 98,8%, swoistość 32,5%	Pozwala na wczesny wypis w ciągu pierwszych godzin	Nie została jeszcze zwalidowana
CoDE-ACS	Diagnoza zawału mięśnia sercowego	AUC 0,953 (95% CI 0,947-0,958)	Uwzględnia wiek, płeć, choroby współistniejące i czas od wystąpienia objawów	Wymaga zaawansowanej technologii do wdrożenia

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Materiały źródłowe

#1 Acute Chest Pain in Adults: Outpatient Evaluation | AAFP
https://www.aafp.org/pubs/afp/issues/2020/1215/p721.html
Approximately 1% of primary care office visits are for chest pain, and 2% to 4% of these patients will have unstable angina or myocardial infarction. […] A combination of age, sex, and type of chest pain can predict the likelihood of coronary artery disease as the cause of chest pain. […] The Marburg Heart Score and the INTERCHEST clinical decision rule can also help estimate ACS risk. […] Patients with suspicion of ACS or changes on electrocardiography should be transported immediately to the emergency department. […] Those at low or intermediate risk of ACS can undergo exercise stress testing, coronary computed tomography angiography, or cardiac magnetic resonance imaging. […] The impression of chest pain is often determined by a combination of clinical symptoms at the time of presentation, physical examination, initial electrocardiography (ECG), and risk factors for ACS.
#2 Non-cardiac chest pain: prognosis and secondary healthcare utilisation – PubMed
https://pubmed.ncbi.nlm.nih.gov/30364505/
Objective: Presentations of non-cardiac chest pain (NCCP) to the emergency department (ED) are increasing. More knowledge of prognosis and healthcare utilisation of patients with NCCP is necessary to optimise their management. […] The all-cause 1-year mortality rate of patients with NCCP was 2.3% compared with 7.2% in patients with cardiac chest pain (CCP) (p0.001) and the occurrence of MACE was 5.1% vs 8.3%, respectively (p=0.026). […] The prognosis of patients with NCCP is better than patients with CCP; however, they are at risk for MACE due to a history of CAD.
#3 Non-cardiac chest pain: prognosis and secondary healthcare utilisation – PubMed
https://pubmed.ncbi.nlm.nih.gov/30364505/
Objective: Presentations of non-cardiac chest pain (NCCP) to the emergency department (ED) are increasing. More knowledge of prognosis and healthcare utilisation of patients with NCCP is necessary to optimise their management. […] The all-cause 1-year mortality rate of patients with NCCP was 2.3% compared with 7.2% in patients with cardiac chest pain (CCP) (p0.001) and the occurrence of MACE was 5.1% vs 8.3%, respectively (p=0.026). […] The prognosis of patients with NCCP is better than patients with CCP; however, they are at risk for MACE due to a history of CAD.
#4 Prognosis of undiagnosed chest pain: linked electronic health record cohort study | The BMJ
https://www.bmj.com/content/357/bmj.j1194
Objective To ascertain long term cardiovascular outcomes in patients whose chest pain remained undiagnosed six months after first presentation. […] Most patients with first onset chest pain do not have a diagnosis recorded at presentation or in the subsequent six months, including those who undergo cardiac investigations. These patients have an increased risk of cardiovascular events for at least five years. […] Risk of long term cardiovascular disease was significantly higher over the whole long term follow-up period in patients with initially unattributed chest pain, compared with patients who had a diagnosis of non-coronary pain. […] The risk of cardiovascular disease in the long term was higher in patients with a diagnostic investigation in the first six months than in those without, regardless of their initial diagnosis. […] Our study shows that initial GP classification of patients with new onset chest pain reflects the likelihood of both underlying current cardiovascular disease and long term risk for future disease.
#5 Prognosis of undiagnosed chest pain: linked electronic health record cohort study | The BMJ
https://www.bmj.com/content/357/bmj.j1194
Objective To ascertain long term cardiovascular outcomes in patients whose chest pain remained undiagnosed six months after first presentation. […] Most patients with first onset chest pain do not have a diagnosis recorded at presentation or in the subsequent six months, including those who undergo cardiac investigations. These patients have an increased risk of cardiovascular events for at least five years. […] Risk of long term cardiovascular disease was significantly higher over the whole long term follow-up period in patients with initially unattributed chest pain, compared with patients who had a diagnosis of non-coronary pain. […] The risk of cardiovascular disease in the long term was higher in patients with a diagnostic investigation in the first six months than in those without, regardless of their initial diagnosis. […] Our study shows that initial GP classification of patients with new onset chest pain reflects the likelihood of both underlying current cardiovascular disease and long term risk for future disease.
#6 30Â day predicted outcome in undifferentiated chest pain: multicenter validation of the HEART score in Tunisian population | BMC Cardiovascular Disorders | Full Text
https://bmccardiovascdisord.biomedcentral.com/articles/10.1186/s12872-021-02381-z
Chest pain remains one of the most challenging serious complaints in the emergency department (ED). A prompt and accurate risk stratification tool for chest pain patients is paramount to help physician effectively prognosticate outcomes. HEART score is considered one of the best scores for chest pain risk stratification. […] To validate HEART score as a prognostication tool, among Tunisian ED patients with undifferentiated chest pain. […] The primary outcome was major cardiovascular events (MACE) occurrence, including all-cause mortality, non-fatal myocardial infarction (MI), and coronary revascularisation over 30 days following the ED visit. […] Within 30 days of ED visit, MACE were reported in 628 (16.2%) patients, with an incidence of 1.2% in the low risk group, 10.8% in the intermediate risk group and 62.4% in the high risk group.
#7 30Â day predicted outcome in undifferentiated chest pain: multicenter validation of the HEART score in Tunisian population | BMC Cardiovascular Disorders | Full Text
https://bmccardiovascdisord.biomedcentral.com/articles/10.1186/s12872-021-02381-z
HEART score showed a good discrimination performance in predicting MACE occurrence at 30 days for Tunisian patients with undifferentiated acute chest pain. […] Our study indicates that the HEART score had a good performance to evaluate the risk of MACE within 30 days in Tunisian patients with undifferentiated acute chest pain. However, its use in clinical decision making should be prudent.
#8
https://link.springer.com/article/10.1007/s12471-011-0154-9
To determine the long-term prognostic value of stress imaging and clinical risk scoring for cardiovascular mortality in chest pain patients after ruling out acute coronary syndrome (ACS). […] For rule-out ACS patients, C-statistics were 0.829 and 0.803 for the GRACE and TIMI scores. […] In multivariate analysis, known chronic heart failure, ACE inhibitor use, and GRACE score were independent predictors of cardiovascular mortality. […] TIMI and GRACE score but not DSE and MPS are accurate predictors of long-term cardiovascular mortality, even in chest pain patients with a normal or non-diagnostic electrocardiogram undergoing a rule-out protocol. […] The GRACE and TIMI risk scores demonstrated a very good discrimination for long-term cardiovascular mortality. […] In conclusion, imaging for inducible myocardial ischaemia by DSE and MPS does not predict long-term cardiovascular mortality in chest pain patients with a normal or non-diagnostic electrocardiogram after ruling out ACS. The TIMI and GRACE scores, however, are accurate predictors in these patients with low long-term cardiovascular mortality.
#9
https://link.springer.com/article/10.1007/s12471-011-0154-9
To determine the long-term prognostic value of stress imaging and clinical risk scoring for cardiovascular mortality in chest pain patients after ruling out acute coronary syndrome (ACS). […] For rule-out ACS patients, C-statistics were 0.829 and 0.803 for the GRACE and TIMI scores. […] In multivariate analysis, known chronic heart failure, ACE inhibitor use, and GRACE score were independent predictors of cardiovascular mortality. […] TIMI and GRACE score but not DSE and MPS are accurate predictors of long-term cardiovascular mortality, even in chest pain patients with a normal or non-diagnostic electrocardiogram undergoing a rule-out protocol. […] The GRACE and TIMI risk scores demonstrated a very good discrimination for long-term cardiovascular mortality. […] In conclusion, imaging for inducible myocardial ischaemia by DSE and MPS does not predict long-term cardiovascular mortality in chest pain patients with a normal or non-diagnostic electrocardiogram after ruling out ACS. The TIMI and GRACE scores, however, are accurate predictors in these patients with low long-term cardiovascular mortality.
#10 Chest pain in general practice: a systematic review of prediction rules | BMJ Open
https://bmjopen.bmj.com/content/9/2/e027081
Objective To identify and assess the performance of clinical decision rules (CDR) for chest pain in general practice. […] Eight studies comprising five CDRs met the inclusion criteria. Three CDRs are designed for rule out of coronary disease in intermittent-type chest pain (Gencer rule, Marburg Heart Score, INTERCHEST), and two for rule out of ACS (Grijseels rule, Bruins Slot rule). […] The Marburg Heart Score was more sensitive in detecting coronary disease than the clinical judgement of the general practitioner. […] In general practice, there is currently no clinical decision aid that can safely rule out ACS. For intermittent chest pain, several rules exist, of which the Marburg Heart Score has been most extensively tested and appears to outperform clinical judgement alone. […] The Marburg Heart Score has been most extensively tested and appears to outperform clinical judgement alone.
#11 Chest pain in general practice: a systematic review of prediction rules | BMJ Open
https://bmjopen.bmj.com/content/9/2/e027081
The other two CDRs for rule out of stable CAD were the INTERCHEST rule and the Gencer rule. […] Overall, the Marburg Heart Score holds most promise for ruling out CAD in patients with intermittent chest pain with a consistent, high sensitivity and acceptable specificity and an NPV of 97.3%98.7% in multiple prospective studies. […] The currently available Grijseels (NPV 82.4%, PPV 56.9%) and Bruins Slot (NPV 91.7%, PPV 23.4%) rules fall short of both these targets. […] Future research is warranted for the role of implementing point-of-care cardiac marker tests into CDRs for acute chest pain, as well as the cost-effectiveness of a Marburg Heart Score work-up strategy for intermittent chest pain.
#12 Acute Chest Pain in Adults: Outpatient Evaluation | AAFP
https://www.aafp.org/pubs/afp/issues/2020/1215/p721.html
A meta-analysis of studies that evaluated the role of previous chest pain in diagnosing ACS concluded that chest pain that is pleuritic, positional, or reproducible with palpation and not related to exertion is low risk for ACS. […] The combination of age, sex, and type of chest pain can predict the likelihood of coronary artery disease (CAD) as the cause of chest pain. […] Validated clinical decision rules can help determine whether chest pain is caused by CAD. […] The INTERCHEST clinical decision rule is a second validated decision rule that can predict the presence or absence of CAD in patients who present with chest pain in the primary care setting. […] Because history alone usually cannot determine whether a patient is actively experiencing cardiac ischemia, a 12-lead ECG should be performed on all patients in whom cardiac ischemia is suspected.
#13 Chest pain in general practice: a systematic review of prediction rules | BMJ Open
https://bmjopen.bmj.com/content/9/2/e027081
The other two CDRs for rule out of stable CAD were the INTERCHEST rule and the Gencer rule. […] Overall, the Marburg Heart Score holds most promise for ruling out CAD in patients with intermittent chest pain with a consistent, high sensitivity and acceptable specificity and an NPV of 97.3%98.7% in multiple prospective studies. […] The currently available Grijseels (NPV 82.4%, PPV 56.9%) and Bruins Slot (NPV 91.7%, PPV 23.4%) rules fall short of both these targets. […] Future research is warranted for the role of implementing point-of-care cardiac marker tests into CDRs for acute chest pain, as well as the cost-effectiveness of a Marburg Heart Score work-up strategy for intermittent chest pain.
#14 Chest pain in general practice: a systematic review of prediction rules | BMJ Open
https://bmjopen.bmj.com/content/9/2/e027081
The other two CDRs for rule out of stable CAD were the INTERCHEST rule and the Gencer rule. […] Overall, the Marburg Heart Score holds most promise for ruling out CAD in patients with intermittent chest pain with a consistent, high sensitivity and acceptable specificity and an NPV of 97.3%98.7% in multiple prospective studies. […] The currently available Grijseels (NPV 82.4%, PPV 56.9%) and Bruins Slot (NPV 91.7%, PPV 23.4%) rules fall short of both these targets. […] Future research is warranted for the role of implementing point-of-care cardiac marker tests into CDRs for acute chest pain, as well as the cost-effectiveness of a Marburg Heart Score work-up strategy for intermittent chest pain.
#15 Chest pain risk Stratification…A Clinical Prediction Rule – Patient Care – EMT City
https://www.emtcity.com/topic/3274-chest-pain-risk-stratificationa-clinical-prediction-rule/
Current risk stratification tools do not identify very-low-risk patients who can be safely discharged without prolonged emergency department (ED) observation, expensive rule-out protocols, or provocative testing. […] We derived a clinical prediction rule that was 98.8% sensitive and 32.5% specific. Patients have very low risk of acute coronary syndrome if they have a normal initial ECG, no previous ischemic chest pain, and age younger than 40 years. […] The Vancouver Chest Pain Rule for early discharge defines a group of patients who can be safely discharged after a brief evaluation in the ED. […] This study developed a clinical decision rule to identify low-risk ED chest pain patients who can be safely discharged within 2 hours of presentation. […] Not surprisingly, this study found that patients younger than 40 years and with normal initial ECG results and no previous ischemic chest pain were at very low risk of acute coronary syndrome.
#16 Chest pain risk Stratification…A Clinical Prediction Rule – Patient Care – EMT City
https://www.emtcity.com/topic/3274-chest-pain-risk-stratificationa-clinical-prediction-rule/
This derivation study should not change clinical practice because it has not yet been validated. […] The Vancouver Chest Pain Rule identifies 32.5% of patients who do not have acute coronary syndrome using information available in the first 2 hours of the ED visit. […] This prediction rule is different from previous risk stratification tools. […] The Vancouver Chest Pain Rule is unique in its ability to identify very-low-risk patients who are suitable for early discharge. […] In summary, the Vancouver Chest Pain Rule defines a group of chest pain patients who can be safely discharged from the ED in the first few hours after arrival.
#17 Circulating microRNA-1 in the diagnosis and predicting prognosis of patients with chest pain: a prospective cohort study | BMC Cardiovascular Disorders | Full Text
https://bmccardiovascdisord.biomedcentral.com/articles/10.1186/s12872-018-0987-x
To investigate the early diagnostic and prognostic value of microRNA-1 in patients with acute chest pain. […] It was not statistically significant for microRNA-1 to forecast future AMI but might prognose mortality of 720 days in chest pain patients. […] Circulating microRNA-1 might diagnose early AMI and predict the prognosis of patients with chest pain. […] The prognostic accuracy of miR-1 and cTnI for short-term MACEs (30 days) and long-term mortality (720 days) in ACP patients by ROC curve analysis were shown in Fig. 3, Table 3. […] Our study suggested that circulating miR-1 might diagnose early AMI in patients with ACP, which was almost equal to cTnI, and diagnostic accuracy could be elevated when combined miR-1 with cTnI. Furthermore, miR-1 might play a role in predicting the prognosis of patients with suspected AMI.
#18
https://link.springer.com/article/10.1007/s12471-011-0154-9
To determine the long-term prognostic value of stress imaging and clinical risk scoring for cardiovascular mortality in chest pain patients after ruling out acute coronary syndrome (ACS). […] For rule-out ACS patients, C-statistics were 0.829 and 0.803 for the GRACE and TIMI scores. […] In multivariate analysis, known chronic heart failure, ACE inhibitor use, and GRACE score were independent predictors of cardiovascular mortality. […] TIMI and GRACE score but not DSE and MPS are accurate predictors of long-term cardiovascular mortality, even in chest pain patients with a normal or non-diagnostic electrocardiogram undergoing a rule-out protocol. […] The GRACE and TIMI risk scores demonstrated a very good discrimination for long-term cardiovascular mortality. […] In conclusion, imaging for inducible myocardial ischaemia by DSE and MPS does not predict long-term cardiovascular mortality in chest pain patients with a normal or non-diagnostic electrocardiogram after ruling out ACS. The TIMI and GRACE scores, however, are accurate predictors in these patients with low long-term cardiovascular mortality.
#19 Frontiers | Inherited transthyretin cardiac amyloidosis presenting with diastolic heart failure and gastrointestinal symptoms: a case report and literature review
https://www.frontiersin.org/journals/cardiovascular-medicine/articles/10.3389/fcvm.2025.1588291/full
The prevalence of Inherited transthyretin cardiac amyloidosis (hATTR-CA) is rising with an aging population and more mutation carriers. Its symptoms often resemble other heart diseases, leading to delayed diagnosis and affecting prognosis. […] This case emphasizes the importance of early diagnosis and accurate treatment of hATTR-CA, particularly the role of imaging in diagnosing myocardial infiltration. […] With early diagnosis and active treatment, the patient’s prognosis improved, symptoms of heart failure were controlled, and quality of life significantly improved. […] Timely identification of CA allows for effective treatment, improving prognosis. […] This case report underscores the importance of an integrated diagnostic approach, particularly the use of multimodal imaging, in the early identification of ATTR-type myocardial amyloidosis. By leveraging multidisciplinary collaboration and advanced diagnostic tools, timely recognition and appropriate treatment can be initiated, significantly improving the patient’s quality of life.
#20 Machine learning for diagnosis of myocardial infarction using cardiac troponin concentrations | Nature Medicine
https://www.nature.com/articles/s41591-023-02325-4
Although guidelines recommend fixed cardiac troponin thresholds for the diagnosis of myocardial infarction, troponin concentrations are influenced by age, sex, comorbidities and time from symptom onset. […] CoDE-ACS had excellent discrimination for myocardial infarction (area under curve, 0.953; 95% confidence interval, 0.9470.958), performed well across subgroups and identified more patients at presentation as low probability of having myocardial infarction than fixed cardiac troponin thresholds (61 versus 27%) with a similar negative predictive value and fewer as high probability of having myocardial infarction (10 versus 16%) with a greater positive predictive value. […] Patients identified as having a low probability of myocardial infarction had a lower rate of cardiac death than those with intermediate or high probability 30days (0.1 versus 0.5 and 1.8%) and 1year (0.3 versus 2.8 and 4.2%; P0.001 for both) from patient presentation.
#21 Machine learning for diagnosis of myocardial infarction using cardiac troponin concentrations | Nature Medicine
https://www.nature.com/articles/s41591-023-02325-4
Although guidelines recommend fixed cardiac troponin thresholds for the diagnosis of myocardial infarction, troponin concentrations are influenced by age, sex, comorbidities and time from symptom onset. […] CoDE-ACS had excellent discrimination for myocardial infarction (area under curve, 0.953; 95% confidence interval, 0.9470.958), performed well across subgroups and identified more patients at presentation as low probability of having myocardial infarction than fixed cardiac troponin thresholds (61 versus 27%) with a similar negative predictive value and fewer as high probability of having myocardial infarction (10 versus 16%) with a greater positive predictive value. […] Patients identified as having a low probability of myocardial infarction had a lower rate of cardiac death than those with intermediate or high probability 30days (0.1 versus 0.5 and 1.8%) and 1year (0.3 versus 2.8 and 4.2%; P0.001 for both) from patient presentation.
#22 Machine learning for diagnosis of myocardial infarction using cardiac troponin concentrations | Nature Medicine
https://www.nature.com/articles/s41591-023-02325-4
CoDE-ACS used as a clinical decision support system has the potential to reduce hospital admissions and have major benefits for patients and health care providers. […] Compared with patients identified by CoDE-ACS at presentation as intermediate or high probability, those who were low probability of myocardial infarction had a lower rate of cardiac death and all-cause death at 30days (cardiac death: 0.1 versus 0.5 and 1.8%; all-cause death: 0.1 versus 0.9 and 2.0%, respectively) and at 1year (cardiac death: 0.3 versus 2.8 and 4.2%; all-cause death: 1.1 versus 6.1 and 6.7%, respectively; log-rank test P0.001).
#23 An active learning machine technique based prediction of cardiovascular heart disease from UCI-repository database | Scientific Reports
https://www.nature.com/articles/s41598-023-40717-1
The final findings demonstrate that when the learning machine classifiers were put to use, the Naive Bayes and RBF neural networks achieved an accuracy of 94.78% when attempting to forecast the presence of coronary cardiovascular disease. However, the Learning Vector Quantization method achieved the highest categorization accuracy of 98.78%, with a specificity of 97.1% and sensitivity of 97.91%, a precision of 98.07% and 95.31%, and 97.89% F1score and F-measure values, respectively.
#24
https://journals.lww.com/annals-of-medicine-and-surgery/fulltext/2025/05000/surgical_outcomes_of_isolated_coronary_artery.6.aspx
The leading cause of death worldwide is coronary artery disease. […] A number of factors, including but not limited to gender, age, comorbidities, duration of cardiopulmonary bypass time, and surgical urgency, influence the short-term mortality following Coronary Artery Bypass Grafting (CABG). […] Survival is significantly impacted by CABG. If at all possible, it is preferable to improve a patients condition before surgery in order to reduce mortality. The patients chance of survival is impacted by complications including stroke and extended intubation. […] Short-term mortality after CABG depends on multiple factors, including but not exclusive to gender, age, comorbidities, length of cardiopulmonary bypass time, and urgency of the operation. […] The CPB and cross-clamp time also had a significant relationship with in-hospital mortality, showing P values of 0.000 and 0.05, respectively.
#25
https://journals.lww.com/annals-of-medicine-and-surgery/fulltext/2025/05000/surgical_outcomes_of_isolated_coronary_artery.6.aspx
The leading cause of death worldwide is coronary artery disease. […] A number of factors, including but not limited to gender, age, comorbidities, duration of cardiopulmonary bypass time, and surgical urgency, influence the short-term mortality following Coronary Artery Bypass Grafting (CABG). […] Survival is significantly impacted by CABG. If at all possible, it is preferable to improve a patients condition before surgery in order to reduce mortality. The patients chance of survival is impacted by complications including stroke and extended intubation. […] Short-term mortality after CABG depends on multiple factors, including but not exclusive to gender, age, comorbidities, length of cardiopulmonary bypass time, and urgency of the operation. […] The CPB and cross-clamp time also had a significant relationship with in-hospital mortality, showing P values of 0.000 and 0.05, respectively.
#26
https://journals.lww.com/annals-of-medicine-and-surgery/fulltext/2025/05000/surgical_outcomes_of_isolated_coronary_artery.6.aspx
The number of vessels bypassed had a significant relationship (P = 0.002) with death in hospital, meaning the number of vessels bypassed and death in hospital was higher. […] We sought to compare the outcomes of surgery with observed mortality in hospitals, and our data suggested complications such as stroke, arrhythmia, and delayed extubation for any reason had a major impact on mortality in hospitals, as the results indicate. […] Multiple papers worldwide suggest that stroke alone is a risk factor for mortality, predicting a 2-fold increase in mortality risk compared to those without a stroke this evident especially in first year after surgery. […] We have concluded that a short stay in the hospital could be beneficial for CABG patients as they could return to their daily activities sooner. Complications such as strokes and prolonged intubation influence the patients survival. Re-exploration, a sinister complication of CABG, warrants a low threshold in certain patients, as the alternative may result in death.
#27
https://journals.lww.com/annals-of-medicine-and-surgery/fulltext/2025/05000/surgical_outcomes_of_isolated_coronary_artery.6.aspx
The number of vessels bypassed had a significant relationship (P = 0.002) with death in hospital, meaning the number of vessels bypassed and death in hospital was higher. […] We sought to compare the outcomes of surgery with observed mortality in hospitals, and our data suggested complications such as stroke, arrhythmia, and delayed extubation for any reason had a major impact on mortality in hospitals, as the results indicate. […] Multiple papers worldwide suggest that stroke alone is a risk factor for mortality, predicting a 2-fold increase in mortality risk compared to those without a stroke this evident especially in first year after surgery. […] We have concluded that a short stay in the hospital could be beneficial for CABG patients as they could return to their daily activities sooner. Complications such as strokes and prolonged intubation influence the patients survival. Re-exploration, a sinister complication of CABG, warrants a low threshold in certain patients, as the alternative may result in death.
#28 Acute Chest Pain in Adults: Outpatient Evaluation | AAFP
https://www.aafp.org/pubs/afp/issues/2020/1215/p721.html
A meta-analysis of studies that evaluated the role of previous chest pain in diagnosing ACS concluded that chest pain that is pleuritic, positional, or reproducible with palpation and not related to exertion is low risk for ACS. […] The combination of age, sex, and type of chest pain can predict the likelihood of coronary artery disease (CAD) as the cause of chest pain. […] Validated clinical decision rules can help determine whether chest pain is caused by CAD. […] The INTERCHEST clinical decision rule is a second validated decision rule that can predict the presence or absence of CAD in patients who present with chest pain in the primary care setting. […] Because history alone usually cannot determine whether a patient is actively experiencing cardiac ischemia, a 12-lead ECG should be performed on all patients in whom cardiac ischemia is suspected.
#29 Acute Chest Pain in Adults: Outpatient Evaluation | AAFP
https://www.aafp.org/pubs/afp/issues/2020/1215/p721.html
A meta-analysis of studies that evaluated the role of previous chest pain in diagnosing ACS concluded that chest pain that is pleuritic, positional, or reproducible with palpation and not related to exertion is low risk for ACS. […] The combination of age, sex, and type of chest pain can predict the likelihood of coronary artery disease (CAD) as the cause of chest pain. […] Validated clinical decision rules can help determine whether chest pain is caused by CAD. […] The INTERCHEST clinical decision rule is a second validated decision rule that can predict the presence or absence of CAD in patients who present with chest pain in the primary care setting. […] Because history alone usually cannot determine whether a patient is actively experiencing cardiac ischemia, a 12-lead ECG should be performed on all patients in whom cardiac ischemia is suspected.
#30 Acute Chest Pain in Adults: Outpatient Evaluation | AAFP
https://www.aafp.org/pubs/afp/issues/2020/1215/p721.html
ECG findings that increase the likelihood of ACS include ST segment elevation, new-onset left bundle branch block, presence of Q waves, or new T-wave inversions. […] For patients with chest pain not requiring immediate referral who have a low to intermediate pretest probability of CAD, exercise stress testing should be considered. […] Evaluating with coronary computed tomography angiography (CCTA) decreases the number of nonfatal acute myocardial infarctions and is moderately more accurate than stress ECG in ruling out CAD in patients with chest pain. […] Cardiac magnetic resonance imaging may be useful in the evaluation of typical angina. […] If the initial evaluation indicates that ACS is less likely or the diagnostic evaluation for ACS in higher-risk patients is negative, other non-ACS conditions that may cause symptoms similar to coronary ischemia should be considered.
#31 Acute Chest Pain in Adults: Outpatient Evaluation | AAFP
https://www.aafp.org/pubs/afp/issues/2020/1215/p721.html
ECG findings that increase the likelihood of ACS include ST segment elevation, new-onset left bundle branch block, presence of Q waves, or new T-wave inversions. […] For patients with chest pain not requiring immediate referral who have a low to intermediate pretest probability of CAD, exercise stress testing should be considered. […] Evaluating with coronary computed tomography angiography (CCTA) decreases the number of nonfatal acute myocardial infarctions and is moderately more accurate than stress ECG in ruling out CAD in patients with chest pain. […] Cardiac magnetic resonance imaging may be useful in the evaluation of typical angina. […] If the initial evaluation indicates that ACS is less likely or the diagnostic evaluation for ACS in higher-risk patients is negative, other non-ACS conditions that may cause symptoms similar to coronary ischemia should be considered.
#32 Acute Chest Pain in Adults: Outpatient Evaluation | AAFP
https://www.aafp.org/pubs/afp/issues/2020/1215/p721.html
ECG findings that increase the likelihood of ACS include ST segment elevation, new-onset left bundle branch block, presence of Q waves, or new T-wave inversions. […] For patients with chest pain not requiring immediate referral who have a low to intermediate pretest probability of CAD, exercise stress testing should be considered. […] Evaluating with coronary computed tomography angiography (CCTA) decreases the number of nonfatal acute myocardial infarctions and is moderately more accurate than stress ECG in ruling out CAD in patients with chest pain. […] Cardiac magnetic resonance imaging may be useful in the evaluation of typical angina. […] If the initial evaluation indicates that ACS is less likely or the diagnostic evaluation for ACS in higher-risk patients is negative, other non-ACS conditions that may cause symptoms similar to coronary ischemia should be considered.
#33 Acute Chest Pain in Adults: Outpatient Evaluation | AAFP
https://www.aafp.org/pubs/afp/issues/2020/1215/p721.html
Approximately 1% of primary care office visits are for chest pain, and 2% to 4% of these patients will have unstable angina or myocardial infarction. […] A combination of age, sex, and type of chest pain can predict the likelihood of coronary artery disease as the cause of chest pain. […] The Marburg Heart Score and the INTERCHEST clinical decision rule can also help estimate ACS risk. […] Patients with suspicion of ACS or changes on electrocardiography should be transported immediately to the emergency department. […] Those at low or intermediate risk of ACS can undergo exercise stress testing, coronary computed tomography angiography, or cardiac magnetic resonance imaging. […] The impression of chest pain is often determined by a combination of clinical symptoms at the time of presentation, physical examination, initial electrocardiography (ECG), and risk factors for ACS.
#34 30Â day predicted outcome in undifferentiated chest pain: multicenter validation of the HEART score in Tunisian population | BMC Cardiovascular Disorders | Full Text
https://bmccardiovascdisord.biomedcentral.com/articles/10.1186/s12872-021-02381-z
Chest pain remains one of the most challenging serious complaints in the emergency department (ED). A prompt and accurate risk stratification tool for chest pain patients is paramount to help physician effectively prognosticate outcomes. HEART score is considered one of the best scores for chest pain risk stratification. […] To validate HEART score as a prognostication tool, among Tunisian ED patients with undifferentiated chest pain. […] The primary outcome was major cardiovascular events (MACE) occurrence, including all-cause mortality, non-fatal myocardial infarction (MI), and coronary revascularisation over 30 days following the ED visit. […] Within 30 days of ED visit, MACE were reported in 628 (16.2%) patients, with an incidence of 1.2% in the low risk group, 10.8% in the intermediate risk group and 62.4% in the high risk group.
#35
https://link.springer.com/article/10.1007/s12471-011-0154-9
To determine the long-term prognostic value of stress imaging and clinical risk scoring for cardiovascular mortality in chest pain patients after ruling out acute coronary syndrome (ACS). […] For rule-out ACS patients, C-statistics were 0.829 and 0.803 for the GRACE and TIMI scores. […] In multivariate analysis, known chronic heart failure, ACE inhibitor use, and GRACE score were independent predictors of cardiovascular mortality. […] TIMI and GRACE score but not DSE and MPS are accurate predictors of long-term cardiovascular mortality, even in chest pain patients with a normal or non-diagnostic electrocardiogram undergoing a rule-out protocol. […] The GRACE and TIMI risk scores demonstrated a very good discrimination for long-term cardiovascular mortality. […] In conclusion, imaging for inducible myocardial ischaemia by DSE and MPS does not predict long-term cardiovascular mortality in chest pain patients with a normal or non-diagnostic electrocardiogram after ruling out ACS. The TIMI and GRACE scores, however, are accurate predictors in these patients with low long-term cardiovascular mortality.
#36 Chest pain in general practice: a systematic review of prediction rules | BMJ Open
https://bmjopen.bmj.com/content/9/2/e027081
Objective To identify and assess the performance of clinical decision rules (CDR) for chest pain in general practice. […] Eight studies comprising five CDRs met the inclusion criteria. Three CDRs are designed for rule out of coronary disease in intermittent-type chest pain (Gencer rule, Marburg Heart Score, INTERCHEST), and two for rule out of ACS (Grijseels rule, Bruins Slot rule). […] The Marburg Heart Score was more sensitive in detecting coronary disease than the clinical judgement of the general practitioner. […] In general practice, there is currently no clinical decision aid that can safely rule out ACS. For intermittent chest pain, several rules exist, of which the Marburg Heart Score has been most extensively tested and appears to outperform clinical judgement alone. […] The Marburg Heart Score has been most extensively tested and appears to outperform clinical judgement alone.
#37 Prognosis of undiagnosed chest pain: linked electronic health record cohort study | The BMJ
https://www.bmj.com/content/357/bmj.j1194
Objective To ascertain long term cardiovascular outcomes in patients whose chest pain remained undiagnosed six months after first presentation. […] Most patients with first onset chest pain do not have a diagnosis recorded at presentation or in the subsequent six months, including those who undergo cardiac investigations. These patients have an increased risk of cardiovascular events for at least five years. […] Risk of long term cardiovascular disease was significantly higher over the whole long term follow-up period in patients with initially unattributed chest pain, compared with patients who had a diagnosis of non-coronary pain. […] The risk of cardiovascular disease in the long term was higher in patients with a diagnostic investigation in the first six months than in those without, regardless of their initial diagnosis. […] Our study shows that initial GP classification of patients with new onset chest pain reflects the likelihood of both underlying current cardiovascular disease and long term risk for future disease.
#38 Machine learning for diagnosis of myocardial infarction using cardiac troponin concentrations | Nature Medicine
https://www.nature.com/articles/s41591-023-02325-4
Although guidelines recommend fixed cardiac troponin thresholds for the diagnosis of myocardial infarction, troponin concentrations are influenced by age, sex, comorbidities and time from symptom onset. […] CoDE-ACS had excellent discrimination for myocardial infarction (area under curve, 0.953; 95% confidence interval, 0.9470.958), performed well across subgroups and identified more patients at presentation as low probability of having myocardial infarction than fixed cardiac troponin thresholds (61 versus 27%) with a similar negative predictive value and fewer as high probability of having myocardial infarction (10 versus 16%) with a greater positive predictive value. […] Patients identified as having a low probability of myocardial infarction had a lower rate of cardiac death than those with intermediate or high probability 30days (0.1 versus 0.5 and 1.8%) and 1year (0.3 versus 2.8 and 4.2%; P0.001 for both) from patient presentation.
#39 Machine learning for diagnosis of myocardial infarction using cardiac troponin concentrations | Nature Medicine
https://www.nature.com/articles/s41591-023-02325-4
CoDE-ACS used as a clinical decision support system has the potential to reduce hospital admissions and have major benefits for patients and health care providers. […] Compared with patients identified by CoDE-ACS at presentation as intermediate or high probability, those who were low probability of myocardial infarction had a lower rate of cardiac death and all-cause death at 30days (cardiac death: 0.1 versus 0.5 and 1.8%; all-cause death: 0.1 versus 0.9 and 2.0%, respectively) and at 1year (cardiac death: 0.3 versus 2.8 and 4.2%; all-cause death: 1.1 versus 6.1 and 6.7%, respectively; log-rank test P0.001).
#40 Acute Chest Pain in Adults: Outpatient Evaluation | AAFP
https://www.aafp.org/pubs/afp/issues/2020/1215/p721.html
ECG findings that increase the likelihood of ACS include ST segment elevation, new-onset left bundle branch block, presence of Q waves, or new T-wave inversions. […] For patients with chest pain not requiring immediate referral who have a low to intermediate pretest probability of CAD, exercise stress testing should be considered. […] Evaluating with coronary computed tomography angiography (CCTA) decreases the number of nonfatal acute myocardial infarctions and is moderately more accurate than stress ECG in ruling out CAD in patients with chest pain. […] Cardiac magnetic resonance imaging may be useful in the evaluation of typical angina. […] If the initial evaluation indicates that ACS is less likely or the diagnostic evaluation for ACS in higher-risk patients is negative, other non-ACS conditions that may cause symptoms similar to coronary ischemia should be considered.
#41 Chest pain in general practice: a systematic review of prediction rules | BMJ Open
https://bmjopen.bmj.com/content/9/2/e027081
The other two CDRs for rule out of stable CAD were the INTERCHEST rule and the Gencer rule. […] Overall, the Marburg Heart Score holds most promise for ruling out CAD in patients with intermittent chest pain with a consistent, high sensitivity and acceptable specificity and an NPV of 97.3%98.7% in multiple prospective studies. […] The currently available Grijseels (NPV 82.4%, PPV 56.9%) and Bruins Slot (NPV 91.7%, PPV 23.4%) rules fall short of both these targets. […] Future research is warranted for the role of implementing point-of-care cardiac marker tests into CDRs for acute chest pain, as well as the cost-effectiveness of a Marburg Heart Score work-up strategy for intermittent chest pain.