Key result
The Emergency Severity Index score poorly predicted 30-day major adverse cardiac events (AUC 0.656) compared with the modified HEAR/T score (AUC 0.796) in patients with suspected ACS.
Why the study?
The Emergency Severity Index (ESI) has significant limitations for accurately triaging patients with suspected ACS, warranting evaluation of its accuracy and the incremental performance of supplementing it with a validated risk-stratification tool.
Does the ESI score accurately predict 30-day major adverse cardiac events in patients with suspected ACS compared to the modified HEAR/T score?
Observational (n=750)
Does the ESI score accurately predict 30-day major adverse cardiac events in patients with suspected ACS compared to the modified HEAR/T score?
Effect estimate: AUC 0.656 vs 0.796
The ESI score is poorly associated with serious outcomes in suspected ACS, and supplementing it with the modified HEAR/T score significantly improves triage accuracy.
Caution against sole reliance on ESI for suspected ACS triage; supports prospective validation of modified HEAR/T to refine ED risk stratification.
BACKGROUND: The Emergency Severity Index (ESI) is a widely used tool to triage patients in emergency departments. The ESI tool is used to assess all complaints and has significant limitation for accurately triaging patients with suspected acute coronary syndrome (ACS). OBJECTIVE: We evaluated the accuracy of ESI in predicting serious outcomes in suspected ACS and aimed to assess the incremental reclassification performance if ESI is supplemented with a clinically validated tool used to risk-stratify suspected ACS. METHODS: We used existing data from an observational cohort study of patients with chest pain. We extracted ESI scores documented by triage nurses during routine medical care. Two independent reviewers adjudicated the primary outcome, incidence of 30-day major adverse cardiac events. We compared ESI with the well-established modified HEAR/T (patient History, Electrocardiogram, Age, Risk factors, but without Troponin) score. RESULTS: Our sample included 750 patients (age, 59 ± 17 years; 43% female; 40% black). A total of 145 patients (19%) experienced major adverse cardiac event. The area under the receiver operating characteristic curve for ESI score for predicting major adverse cardiac event was 0.656, compared with 0.796 for the modified HEAR/T score. Using the modified HEAR/T score, 181 of the 391 false positives (46%) and 16 of the 19 false negatives (84%) assigned by ESI could be reclassified correctly. CONCLUSION: The ESI score is poorly associated with serious outcomes in patients with suspected ACS. Supplementing the ESI tool with input from other validated clinical tools can greatly improve the accuracy of triage in patients with suspected ACS.
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Frisch et al. (2020) conducted an observational in Suspected acute coronary syndrome (ACS) (n=750). Emergency Severity Index (ESI) score vs. Modified HEAR/T score was evaluated on Incidence of 30-day major adverse cardiac events (AUC 0.656 vs 0.796). The Emergency Severity Index score poorly predicted 30-day major adverse cardiac events (AUC 0.656) compared with the modified HEAR/T score (AUC 0.796) in patients with suspected ACS.
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