Prognosticating Clinical Prediction Scores Without Clinical Gestalt for Patients With Chest Pain in the Emergency Department

Published:November 27, 2017DOI:



      Assessment of patients with chest pain is a regular challenge in the emergency department (ED). Recent guidelines recommended quantitative assessment of ischemic risk by means of risk scores.


      Our aim was to assess the performance of Thrombosis in Myocardial Infarction (TIMI); Global Registry of Acute Coronary Events (GRACE); history, electrocardiogram, age, risk factors, and troponin (HEART) scores; and the North America Chest Pain Rule (NACPR) without components of clinical gestalt in predicting 30-day major adverse cardiac events (MACE).


      We performed a prospective cohort study in adult patients who attended the ED with undifferentiated chest pain. Clinical prediction rules were applied and calculated. The clinical prediction rules were modified from the original ones, excluding components requiring judgment by clinical gestalt. The primary outcome was MACE. Performance of the tests were evaluated by receive operating characteristic curves and the area under curves (AUC).


      There were 1081 patients included in the study. Thirty-day MACE occurred in 164 (15.2%) patients. The AUC of the GRACE score was 0.756, which was inferior to the TIMI score (AUC 0.809) and the HEART score (AUC 0.845). A TIMI score ≥ 1 had a sensitivity of 97% and a specificity of 45.7%. A GRACE score ≥ 50 had a sensitivity of 99.4% and a specificity of 7.5%. A HEART score ≥ 1 had a sensitivity of 98.8% and a specificity of 11.7%. The NACPR had a sensitivity of 93.3% and a specificity of 51.5%.


      Without clinical gestalt, the modified HEART score had the best discriminative capacity in predicting 30-day MACE.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Goodacre S.
        • Cross E.
        • Arnold J.
        • et al.
        The health care burden of acute chest pain.
        Heart. 2005; 91: 229-230
        • Launbjerg J.
        • Fruergaard P.
        • Hesse B.
        • et al.
        Long-term risk of death, cardiac events and recurrent chest pain in patients with acute chest pain of different origin.
        Cardiology. 1996; 87: 60-66
        • Hollander J.E.
        Risk stratification of emergency department patients with chest pain: the need for standardized reporting guidelines.
        Ann Emerg Med. 2004; 43: 68-70
        • Bernstein S.L.
        • Aronsky D.
        • Duseja R.
        • et al.
        The effect of emergency department crowding on clinically oriented outcomes.
        Acad Emerg Med. 2009; 16: 1-10
        • Amsterdam E.A.
        • Wenger N.K.
        • Brindis R.G.
        • et al.
        2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
        Circulation. 2014; 130: 2354-2394
        • Roffi M.
        • Patrono C.
        • Collet J.P.
        • et al.
        Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology.
        Eur Heart J. 2016; 37: 267-315
        • Antman E.M.
        • Cohen M.
        • Bernink P.J.
        • et al.
        The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making.
        JAMA. 2000; 284: 835-842
        • Granger C.B.
        • Goldberg R.J.
        • Dabbous O.
        • et al.
        Predictors of hospital mortality in the global registry of acute coronary events.
        Arch Intern Med. 2003; 163: 2345-2353
        • Six A.J.
        • Backus B.E.
        • Kelder J.C.
        Chest pain in the emergency room: value of the HEART score.
        Neth Heart J. 2008; 16: 191-196
        • Hess E.P.
        • Brison R.J.
        • Perry J.J.
        • et al.
        Development of a clinical prediction rule for 30-day cardiac events in emergency department patients with chest pain and possible acute coronary syndrome.
        Ann Emerg Med. 2012; 59: 115-125
        • Ramsay G.
        • Podogrodzka M.
        • McClure C.
        • et al.
        Risk prediction in patients presenting with suspected cardiac pain: the GRACE and TIMI risk scores versus clinical evaluation.
        QJM. 2007; 100: 11-18
        • Granger C.B.
        Strategies of patient care in acute coronary syndromes: rationale for the Global Registry of Acute Coronary Events (GRACE) registry.
        Am J Cardiol. 2000; 86: 4M-9M
      1. GRACE 2.0 Calculator. Available at: Accessed September 20, 2016.

        • Thygesen K.
        • Alpert J.S.
        • Jaffe A.S.
        • et al.
        Third universal definition of myocardial infarction.
        Circulation. 2012; 126: 2020-2035
        • DeLong E.R.
        • DeLong D.M.
        • Clarke-Pearson D.L.
        Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach.
        Biometrics. 1988; 44: 837-845
        • Backus B.E.
        • Six A.J.
        • Kelder J.C.
        • et al.
        A prospective validation of the HEART score for chest pain patients at the emergency department.
        Int J Cardiol. 2013; 168: 2153-2158
        • Six A.J.
        • Cullen L.
        • Backus B.E.
        • et al.
        The HEART score for the assessment of patients with chest pain in the emergency department: a multinational validation study.
        Crit Pathw Cardiol. 2013; 12: 121-126
        • Pollack Jr., C.V.
        • Sites F.D.
        • Shofer F.S.
        • et al.
        Application of the TIMI risk score for unstable angina and non-ST elevation acute coronary syndrome to an unselected emergency department chest pain population.
        Acad Emerg Med. 2006; 13: 13-18
        • Mahler S.A.
        • Riley R.F.
        • Hiestand B.C.
        • et al.
        The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge.
        Circ Cardiovasc Qual Outcomes. 2015; 8: 195-203
        • de Araújo Gonçalves P.
        • Ferreira J.
        • Aguiar C.
        • et al.
        TIMI, PURSUIT, and GRACE risk scores: sustained prognostic value and interaction with revascularization in NSTE-ACS.
        Eur Heart J. 2005; 26: 865-872
        • Sakamoto J.T.
        • Liu N.
        • Koh Z.X.
        • et al.
        Comparing HEART, TIMI, and GRACE scores for prediction of 30-day major adverse cardiac events in high acuity chest pain patients in the emergency department.
        Int J Cardiol. 2016; 221: 759-764
        • Marcoon S.
        • Chang A.M.
        • Lee B.
        • et al.
        HEART score to further risk stratify patients with low TIMI scores.
        Crit Pathw Cardiol. 2013; 12: 1-5
        • Sun B.C.
        • Laurie A.
        • Fu R.
        • et al.
        Comparison of the HEART and TIMI risk scores for suspected acute coronary syndrome in the emergency department.
        Crit Pathw Cardiol. 2016; 15: 1-5
        • Lui C.T.
        • Lam H.
        • Cheung K.H.
        • et al.
        Role of copeptin in dual-cardiac marker strategy for patients with chest pain presented to ED.
        Am J Emerg Med. 2015; 33: 1732-1736
        • Than M.
        • Cullen L.
        • Reid C.M.
        • et al.
        A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study.
        Lancet. 2011; 377: 1077-1084