12/9/2023 0 Comments Timi score cad risk factor![]() ![]() In a meta-analysis of studies of the EDACS score that included 11,578 patients, 55% identified as low risk with a 30-day MACE rate of 0.5 %. In a prospective implementation study of the HEART score involving 4,761 patients, 30.7% were deemed low risk and considered for discharge if their HEART score was ≤3 and serial hs-cTn was <99th percentile over 3 hours. This population is likely to benefit from the application of a risk score. Patients with intermediate hs-cTn values who do not rule out at presentation or by the 0/1-hour algorithm require at least a 3-hour value ≤99th percentile to exclude MI. 14 We believe that the use of a formal risk score in those who rule-out by the 0/1-hour algorithm is optional. ![]() 12,13 A European Society of Cardiology task force recommends that patients who rule-out within 1 hour be discharged for outpatient evaluation. Similar algorithms have been developed with various assays for 0/2-hour algorithms. What remains unclear is whether a formal risk score is required or whether clinical judgement is enough, upon reviewing the history and electrocardiogram, to decide on the disposition of patients that rule-out by the 0/1-hour algorithm. 11 Calculation of the HEART and EDACS scores was done and available to the clinicians, but use of the scores in medical decision-making was not mandated. A prospective randomized trial of 3,378 patients comparing a 0/1-hour to 0/3-hour algorithm demonstrated no difference in 30-day MACE between the 2 groups (0.6% in 0/3-hour group and 0.4% in the 0/1-hour group). There was no formal risk score applied in this study. At 30 days in the rule-out group, the MACE rate was 0.2%. In the rule-out group, 71% of patients were discharged for outpatient management. 10 This study involved 2,296 patients, and 62% of the patients met the criteria for rule-out. A prospective study involving 2 centers used the 0/1-hour algorithm for actual patient care. Those with a HEART score ≤3 had a 30-day MACE rate of only 0.2% those with a HEART score ≥4 had a MACE rate of 2.3%. 9 The HEART score was able to distinguish between very low-risk and higher-risk patients. One retrospective study of the 0/1-hour algorithm with 1,282 patients using the hs-cTnT assay applied the HEART score. Most studies evaluating the 0/1-hour algorithm have been retrospective. Risk scores are not needed in patients with very low hs-cTn levels at presentation. 8 Thus, patients with very low levels at presentation are highly unlikely to suffer an acute MI and are at very low risk for 30-day MACE. There was no significant difference between 30-day cardiac death/MI between the strategies: 0.3% in the rapid strategy and 0.4% in the standard strategy. 7 A recent multicenter randomized study of 31,492 patients compared a rapid rule-out strategy at presentation with hs-cTnI <5 ng/L to serial hs-cTnI over 6-12 hours after symptom onset. In a meta-analysis of 22,457 patients from 19 studies, 49.1% of patients had a hs-cTnI <5 ng/L, and the 30-day MACE rate was 0.5%. Serial values ≤99th percentile over 3 hoursīecause there is no standardization among various hs-cTn assays, the actual numbers used in the protocols are different (Figure 1).įigure 1: Rule-Out Non-ST-Segment Elevation MI. ![]() Low levels at presentation but not changing significantly at 1-2 hours.Very low levels at presentation (near or at the level of detection).The use of the newer algorithms allows MI to be excluded in 3 ways: The prognostic ability of low-level hs-cTn measurements lessens the need for the use of risk scores. There have been no prospective trials comparing EDACS to HEART, so neither score is clearly superior to the other. ≥3 risk factors or known coronary artery diseaseĮach component is summed to give a final score In a survey of ED physicians, the acceptable risk for major adverse cardiac events (MACE) (death/MI) soon after discharge was 65ĥ0% or other coronary artery >70% stenosis):Īge 18-15 and either ≥3 cardiac risk factors or known coronary artery disease (previous acute MI, coronary artery bypass graft, or percutaneous coronary intervention) Patients with intermediate hs-cTn values can have the HEART (History, ECG, Age, Risk Factors, Troponin) or EDACS (Emergency Department Assessment of Chest Pain Score) score utilized to assist in disposition.Įvaluation of patients in the ED for possible MI remains a major concern.Most patients who rule-out for myocardial infarction (MI) with very low levels of high-sensitivity cardiac troponin (hs-cTn) at presentation, or not changing significantly at 1-2 hours, can be discharged from the emergency department (ED) without further cardiac testing (stress testing or imaging). ![]()
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