Chest Pain Scores Kristopher Maday, MS, PA-C Program Director/Associate Professor University of Tennessee Health Science Center Physician Assistant Program
Chest Pain Scores
Kristopher Maday, MS, PA-CProgram Director/Associate Professor
University of Tennessee Health Science CenterPhysician Assistant Program
Why Do We Care?
Walker G. EM News. 2015;37(8):310-32
1 : 1816 1 : 16030hr per week50wk per year
2.5 patients per hour5-10% chest pain patients
Every chest pain patient for 5 years to prevent one bad outcome
The Scores• PURSUIT• TIMI• GRACE• FRISC• HEART• EDACS
PURSUIT Trial• Published in 2000• Aim– Predict 30-day risk of death/AMI in
patients with ACS• Design– 9461 patients– 726 hospitals in 28 countries
Boersma E. Circulation. 2000;101(22):2557-2567
Boersma E. Circulation. 2000;101(22):2557-2567
I will cath you
≥ 20%
Thrombolysis in Myocardial Infarction
• Original Study– Published in 2000– Aim
• Create simple risk score for UA/NSTEMI to predict 14-day risk of all cause mortality, AMI, or need for urgent revascularization
– Design• 7081 patients
– Combined patients from TIMI 11b and ESSENCE trial• International, randomized, double-blind
• Validated in 2006Antman EM. JAMA. 2000;282(7):835-842 Pollack CV. Acad Emerg Med. 2006;13(1):13-18
Antman EM. JAMA. 2000;282(7):835-842
Age ≥ 65
≥ 3 CAD Risk Factors
≥ 2 episodes of severe angina in past 24hr
ASA Use in Past 7 days
Known CAD (≥50% stenosis)
ST changes ≥ 0.5mm on EKG
(+) Cardiac Enzyme
(+) FH of CADHTNHLDDM(+) smoker
I will cath you
≥ 4
Global Registry of Acute Coronary Events
• Original Study– Published in 2006– Aim• Predict 6-month risk of death/AMI in patients
with ACS– Design• 43810 patients• 94 hospitals in 14 countries
• Validated in 2009
Fox KA. BMJ. 2006;333(7578):1091 Elbarouni B. Am Heart J. 2009;158(3):392-299
Fox KA. BMJ. 2006;333(7578):1091 Elbarouni B. Am Heart J. 2009;158(3):392-299
GRACE Score Mortality Risk
0-87 0-2%
88-128 3-10%
129-149 10-20%
150-173 20-30%
174-182 40%
183-190 50%
200-207 70%
208-284 90%
≥ 285 99%
FastRevascularizationinInStabilityin Coronary disease
FRISC Score• 1999 – Original study– Primary Aim• Early vs traditional revacularization in chest
pain patients• 58 Scandanavian hospitals• 2457 patients
• 2005 – Analyzed independent variables– Primary aim• Identification of chest pain patients who
would most benefit from early revascularizationFRISC II Investigators. Lancet. 1999;354:708–715 Lagerqvist B. Heart. 2005;91(8):1047-1052
Age ≥ 70MaleDiabetesPrevious AMIST depressionElevated troponinElevated CRP/IL-6
Lagerqvist B. Heart. 2005;91(8):1047-1052
I will cath you
≥ 3
HEART Pathway• Original Study– Published in 2008– Aim• Develop risk score for chest pain patients
presenting to the ED– Design• 122 patients, single center study
• Validated in 2013
Six AJ. Neth Heart J. 2008;16(6):191-196 Backus BE. Int J Cardiol. 2013;168 (3):2153-2158
Six AJ. Neth Heart J. 2008;16(6):191-196 Rezaie S. REBEL EM Blog. 2014.
EDACS• Published in 2014• Aim– Derive a chest pain score for an
accelerated diagnostic protocol• Design– 1974 patients– 2 hospitals
• Self-validated with additional 608 patients
Than M. Emerg Med Australas. 2014;26(1):34-44
Than M. Emerg Med Australas. 2014;26(1):34-44
Than M. Emerg Med Australas. 2014;26(1):34-44
Low RiskEDACS < 16 AND no ischemia on EKG AND 0/2hr troponin (-)
Not Low RiskEDACS ≥ 16 OR new ischemia on EKG OR 0/2hr troponin (+)
I will cath you
Take Home Points• Risk stratification
•Discharge low risk chest pain
•Use clinical gestalt
Thank You!
w w w . p a i n e p o d c a s t . c o m