Risk Stratification in Chest Pain: Impact on the Diagnosis of Acute Coronary Syndrome

Abstract Background The implementation of institutional protocols in the emergency department (ED) for risk stratification in patients with chest pain has been recommended. Objective To assess the sensitivity, specificity and predictive value of an institutional risk stratification protocol for chest pain suggestive of acute coronary syndrome (ACS). Method Cross-sectional study conducted based on the computerized records of patients treated with the use of a chest pain protocol adapted from the Manchester protocol. The level of risk was stratified by applying five colors representing the respective levels. Each color represents a level of severity and a maximum waiting time for receiving medical care. Red and orange were considered to be high priority, while patients with yellow, green or blue indications were considered to represent a low priority. To compare the type of diagnosis and the classification of priority for receiving care, the Pearson's chi-square test was used, considering a significance level of p< 0.05 for all tests. Results The records of 1,074 patients admitted to the cardiology ED were analyzed. Men (54%), with a mean age of 60 ± 15 years, with complaints of chest pain (44%) of moderate intensity (80%) were predominant the study. Of these patients, 19% were classified as high priority, while 81% were considered to represent a low priority. ACS was confirmed in 23% of the patients, with 34% of them being classified as high priority and 66% as low priority. The sensitivity of the risk stratification protocol for chest pain was 33.7% and the specificity was 86.0%, with a positive and negative predictive value of 41.7% and 81.3%, respectively. Conclusion The Institutional risk stratification protocol for chest pain suggestive of ACS presented satisfactory specificity and a low degree of sensitivity. Int J Cardiovasc Sci. 2020; [online].ahead print, PP.0-0

Valor preditivo da frequência cardíaca em repouso do teste ergométrico na mortalidade / Predictive value of resting heart rate for cardiovascular and all-cause mortality / Valor predictivo de la frecuencia cardíaca en reposo del test ergométrico en la mortalidad

FUNDAMENTO: A frequência cardíaca em repouso (cuja média está entre 60 e 80 bpm) é uma das mais simples variáveis cardiovasculares e tem sido considerada como um preditor de mortalidade cardiovascular e geral. OBJETIVO: Avaliar o valor preditivo da frequência cardíaca em repouso (FCR), antes do teste ergométrico (TE), na mortalidade cardiovascular (CV) e geral. MÉTODOS: Estudo de caso-controle, que utilizou informações contidas nos bancos de dados do laboratório de ergometria de um hospital especializado em cardiologia e os registros de óbitos da Secretaria da Saúde em uma cidade do sul do Brasil, de janeiro de 1995 a junho de 2007. Foram analisados 7.055 pacientes, sendo 1.645 (23,3 por cento) do grupo caso (óbitos) e 5.410 (76,7 por cento) do grupo controle (vivos). Foi calculado o ponto de corte da FCR para mortalidade, através da curva ROC e realizada a análise multivariada para as variáveis selecionadas. Os desfechos foram mortalidade CV e geral. RESULTADOS: A incidência de mortalidade CV foi de 674 casos (9,5 por cento); a FCR > 78 bpm foi o ponto de corte. Após ajustado para as variáveis selecionadas, o odds ratio (OR) para FCR > 78 bpm foi de 3,5 (IC 95 por cento = 2,9 - 4,2) para mortalidade CV e 3,6 (IC 95 por cento = 3,2 - 4,0) para mortalidade geral. CONCLUSÃO: A FCR > 78 bpm é um preditor independente de mortalidade cardiovascular e geral.

BACKGROUND: Resting heart rate (which ranges from 60 to 80 bpm) is one of the simplest cardiovascular parameters, and has been considered as a predictor of cardiovascular and all-cause mortality. OBJECTIVE: To determine the predictive value of resting heart rate (RHR) before exercise stress testing (ET) for cardiovascular (CV) and all-cause mortality. METHODS: This was a case-control study using data from the database of the Exercise Testing Laboratory of a cardiac hospital and the death records of the Health Department of a city located in the South of Brazil from January 1995 to June 2007. A total of 7,055 patients were studied; 1,645 (23.3 percent) in the case group (deceased) and 5,410 (76.7 percent) in the control group (alive). The cut-off value of RHR for mortality was derived from the ROC curve, and a multivariate analysis was performed for the selected variables. The study's outcome measures were cardiovascular and all-cause mortality. RESULTS: Six hundred and seventy-four patients died of cardiovascular diseases (9.5 percent); the cut-off value was RHR > 78 bpm). After adjusting for selected variables, the odds ratio (OR) of RHR > 78 bpm was 3.5 (95 percent CI 2.9 to 4.2) for CV mortality and 3.6 (95 percent CI 3.2 to 4.0) for all-cause mortality. CONCLUSION: Resting heart rate > 78 is an independent predictor of cardiovascular and all-cause mortality.

FUNDAMENTO: La frecuencia cardíaca en reposo (cuya media está entre 60 y 80 lpm) es una de las más simples variables cardiovasculares y ha sido considerada como un predictor de mortalidad cardiovascular y general.' OBJETIVO: Evaluar el valor predictivo de la frecuencia cardíaca en reposo (FCR), antes del test ergométrico (TE), en la mortalidad cardiovascular (CV) y general. MÉTODOS: Estudio de caso-control, que utilizó informaciones contenidas en los bancos de datos del laboratorio de ergometría de un hospital especializado en cardiología y los registros de óbitos de la Secretaría de Salud en una ciudad del sur del Brasil, de enero de 1995 a junio de 2007. Fueron analizados 7.055 pacientes, siendo 1.645 (23,3 por ciento) del grupo caso (óbitos) y 5.410 (76,7 por ciento) del grupo control (vivos). Fue calculado el punto de corte de la FCR para mortalidad, a través de la curva ROC y realizado el análisis multivariado para las variables seleccionadas. Los desenlaces fueron mortalidad CV y general. RESULTADOS: La incidencia de mortalidad CV fue de 674 casos (9,5 por ciento); la FCR > 78 lpm fue el punto de corte. Después de ajustado para las variables seleccionadas, el odds ratio (OR) para FCR > 78 lpm fue de 3,5 (IC 95 por ciento = 2,9 - 4,2) para mortalidad CV y 3,6 (IC 95 por ciento = 3,2 - 4,0) para mortalidad general. CONCLUSIÓN: La FCR > 78 lpm es un predictor independiente de mortalidad cardiovascular y general.