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