The value of clinical and laboratory diagnostics for chest pain patients at the emergency department

Background: The focus during the diagnostic process for patients with acute chest pain is to discriminate patients who can be safely discharged from those who are at risk for an acute coronary syndrome (ACS). In this study the diagnostic value of the clinical examination is compared with laboratory testing of troponin. Methods: This study included 710 chest pain patients who presented at the ED of two hospitals in the Netherlands. Clinical examination and laboratory testing were combined in the recently developed HEART-score. The diagnostic values of clinical presentation, troponin and the HEART-score for a major adverse coronary event (MACE) and an ACS within 6 weeks were assessed. Furthermore, the improvement of HEART with the second troponin measurement after 6 h was assessed using the net reclassification improvement (NRI). Results: The use of HEART (AUC(MACE) : 0.77; AUC(ACS) : 0.82) obtains a higher diagnostic value than troponin (AUC(MACE) : 0.72; AUC(ACS) : 0.74) or clinical evaluation (AUC(MACE) : 0.69; AUC(ACS) : 0.74). Statistical significant different AUCs were obtained when HEART is compared to troponin or clinical evaluation (p < 0.01). The use of the second troponin test (after 6 h of admission) within HEART resulted in an improvement of 8.0%. Conclusions: The HEART-score combines clinical evaluation and results from laboratory testing, which should be used together, to discriminate patients at risk of a cardiac event from patients who can be safely discharged. In addition, it is shown that a second troponin measurement slightly improves the discriminative ability of the HEART-score.