Clinical Risk Stratification in the Emergency Department Predicts Long-Term Cardiovascular Outcomes in a Population-Based Cohort Presenting with Acute Chest Pain: Primary Results of the Olmsted County Chest Pain Study

摘要

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 Olmsted County EDs. 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 non-cardiac origin were excluded. Main outcome measures were major adverse cardiovascular and cerebrovascular events (MACCE) at 30 days and a median follow up of 7.3 years, and mortality through a median of 16.6 years. The 2271 patients were classified: 436 (19.2%) as high-, 1,557 (68.6%) as intermediate- and 278 (12.2%) as low-risk. Thirty-day MACCE occurred in 11.5% in high-risk, 6.2% in intermediate-risk, and 2.5% in the lowrisk group (p<0.001). At 7.3 years, significantly more MACCE were recorded in the intermediate (HR 1.91; 95% 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 compared to lowrisk patients at 16.6 years. At 7.3 and 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 optimization of their cardiovascular risk management.