High-risk classification by AHCPR criteria in ED chest pain patients predicted higher 30-day MACCE (11.5% vs 2.5%) and 7.3-year MACCE (HR 2.45; 95% CI 1.67-3.58) compared to low-risk patients.
Cohort (n=2,271)
Yes
Does clinical risk stratification using AHCPR criteria predict long-term cardiovascular outcomes and mortality in patients presenting to the ED with acute chest pain?
A rapid clinical algorithm using AHCPR criteria applied in the emergency department reliably predicts long-term mortality and cardiovascular outcomes in patients with acute chest pain.
Hazard Ratio: 2.45 (95% CI 1.67–3.58)
The long-term cardiovascular outcomes of a population-based cohort presenting to the emergency department (ED) with chest pain and classified with a clinical risk stratification algorithm are not well documented. The Olmsted County Chest Pain Study is a community-based study that included all consecutive patients presenting with chest pain consistent with unstable angina presenting to all EDs in Olmsted County, Minnesota. Patients were classified according to the Agency for Health Care Policy and Research (AHCPR) criteria. Patients with ST elevation myocardial infarction and chest pain of noncardiac origin were excluded. Main outcome measures were major adverse cardiovascular and cerebrovascular events (MACCE) at 30 days and at a median follow-up of 7.3 years, and mortality through a median of 16.6 years. The 2271 patients were classified as follows: 436 (19.2%) as high risk, 1557 (68.6%) as intermediate risk, and 278 (12.2%) as low risk. Thirty-day MACCE occurred in 11.5% in the high-risk group, 6.2% in the intermediate-risk group, and 2.5% in the low-risk group (p < 0.001). At 7.3 years, significantly more MACCE were recorded in the intermediate-risk (hazard ratio HR, 1.91; 95% confidence intervals CI, 1.33-2.75) and high-risk groups (HR, 2.45; 95% CI, 1.67-3.58). Intermediate- and high-risk patients demonstrated a 1.38-fold (95% CI, 0.95-2.01; p = 0.09) and a 1.68-fold (95% CI, 1.13-2.50; p = 0.011) higher mortality, respectively, compared to low-risk patients at 16.6 years. At 7.3 and at 16.6 years of follow-up, biomarkers were not incrementally predictive of cardiovascular risk. In conclusion, a widely applicable rapid clinical algorithm using AHCPR criteria can reliably predict long-term mortality and cardiovascular outcomes. This algorithm, when applied in the ED, affords an excellent opportunity to identify patients who might benefit from a more aggressive cardiovascular risk factor management strategy. Abbreviations: ACC = American College of Cardiology, AHA = American Heart Association, AHCPR = Agency for Health Care Policy and Research, CI = confidence intervals, ECG = electrocardiogram, ED = emergency department, GRACE = Global Registry of Acute Coronary Events, HR = hazard ratio, MACCE = major adverse cardiovascular and cerebrovascular events, STEMI = ST elevation myocardial infarction, TIMI = Thrombolysis in Myocardial Infarction, TRS = derivation of the TIMI risk score, UA/NSTEMI = unstable angina/non-ST-segment elevation myocardial infarction.
Farkouh et al. (Tue,) conducted a cohort in Acute chest pain consistent with unstable angina (n=2,271). High-risk classification by AHCPR criteria vs. Low-risk classification was evaluated on Major adverse cardiovascular and cerebrovascular events (MACCE) at a median follow-up of 7.3 years (HR 2.45, 95% CI 1.67-3.58). High-risk classification by AHCPR criteria in ED chest pain patients predicted higher 30-day MACCE (11.5% vs 2.5%) and 7.3-year MACCE (HR 2.45; 95% CI 1.67-3.58) compared to low-risk patients.