ABC | Volume 114, Nº5, May 2020

Original Article HEART, TIMI, and GRACE Scores for Prediction of 30-Day Major Adverse Cardiovascular Events in the Era of High-Sensitivity Troponin Felipe Torralba, 1 Alberto Navarro, 1 Juan Castellanos-de la Hoz, 1 Carlos Ortiz, 1 Alberth Botero, 1 Freddy Alarcón, 1 Nicolas Isaza, 1 D aniel Isaza 1 Fundacion Cardioinfantil Instituto de Cardiologia, 1 Bogota Cundinamarca – Colombia Mailing Address: Felipe Torralba • Fundacion Cardioinfantil Instituto de Cardiologia - ak19#128b66 402 Bogota, Cundinamarca, 111121 – Colombia E-mail: feliptorr1@gmail.com Manuscript received March 22, 2019, revised manuscript June 02, 2019, accepted July 17, 2019 DOI: https://doi.org/10.36660/abc.20190206 Abstract Background: Multiple scoring systems have been designed to calculate the risk of major adverse cardiovascular events (MACE) in patients with chest pain. There is no data on whether the HEART score outperforms TIMI and GRACE in the prediction of MACE, especially in the era of high-sensitivity troponin assay and in an exclusively Latin-American population. Objective: To compare the performance of the HEART, TIMI, and GRACE scores for predicting major cardiovascular events at 30 days of follow-up, in patients who consult for chest pain in the emergency department. Methods: HEART, TIMI, and GRACE scores were analyzed in 519 patients with chest pain at the emergency department. The primary endpoint was the occurrence of MACE within 30 days. The performance of the HEART score was compared with the TIMI and GRACE scores using the DeLong test with p values of 0.05 considered statistically significant. Results: A total of 224 patients (43%) had MACE at 30 days. The C statistic for the HEART, TIMI, and GRACE score was 0.937, 0.844, and 0.797 respectively (p < 0.0001). A HEART score of 3 or less had a sensitivity of 99.5% and a negative predictive value of 99% to classify low risk patients correctly; both values were higher than those obtained by the other scores. Conclusion: The HEART score more effectively predicts cardiovascular events at 30 days of follow-up compared to the other scores. High-sensitivity troponins maintain this score’s previously demonstrated superiority. This score offers more precise identification of low-risk patients. (Arq Bras Cardiol. 2020; 114(5):795-802) Keywords: Cardiovascular Diseases/mortality; Chest Pain; Myocardial Infarction; Forecasting Risk Assessment; Risk Factors; Troponin; Myocardial Ischemia. Introduction Chest pain is one of the most common complaints in patients presenting to the emergency department, with approximately 15 million patient visits in the United States and Europe. 1 It is estimated that 55% of these patients have a non-cardiac cause for chest pain and only one fifth are definitively diagnosed with acute coronary syndromes. 1,2 Approximately 85% of patients with chest pain are admitted, in spite of the fact that up to 60% of cases could be managed in the outpatient setting. 3 In Colombia, cardiovascular diseases are also a cause of high mortality; among these, ischemic heart disease was the main cause in the previous decade, accounting for 49.5% of the total in this group. 4,5 The annual cost of treatment for patients with chest pain of non-cardiac cause can be as high as 8 billion dollars in the USA and approximately 3.9 billion dollars in Colombia. 6 These expenses originate primarily from daily bed costs and radiological and laboratory studies. 2,7,8 This significant economic impact has driven efforts to develop alternatives that enable more efficient use of resources, particularly in countries with limited health budgets. 3,8,9 The development of a tool to accurately determine the risk of major adverse cardiovascular events (MACE) in these patients is essential, and scoring systems such as TIMI and GRACE have been designed to address this problem. 10,11 More recently, the HEART score was created, being the first one prospectively designed to predict MACE. 12-14 The HEART score has outperformed the TIMI and GRACE scores in Asian, European, and North American populations. 11,15 This study aimed to compare the accuracy of these scores for predicting MACE in a group of Latin-American patients with chest pain who presented to a cardiovascular reference center. To the best of our knowledge, this is the first prospective study of this nature. Methods This is a prospective observational study of diagnostic tests carried out in the Fundación Cardioinfantil, located in Bogotá, Colombia. It is a high-complexity hospital specialized 795