A clinical score to obviate the need for cardiac stress testing in patients with acute chest pain and negative troponins

Abstract Introduction Although cardiac stress testing may help establish the safety of early discharge in patients with suspected acute coronary syndromes and negative troponins, more cost-effective strategies are necessary. We aimed to develop a clinical prediction rule to safely obviate the need for cardiac stress testing in this setting. Methods A decision rule was derived in a prospective cohort of 3001 patients with acute chest pain and negative troponins, and validated in a set of 1473 subjects. The primary endpoint was a composite of positive cardiac stress testing (in the absence of a subsequent negative coronary angiogram), positive coronary angiography, or any major coronary events within 3 months. Results A score chart was built based on 7 variables: male gender (+ 2), age (+ 1 per decade from the fifth decade), diabetes mellitus (+ 2), hypercholesterolemia (+ 1), prior coronary revascularization (+ 2), type of chest pain (typical angina: + 5; nonanginal chest pain: − 3), and nondiagnostic repolarization abnormalities (+ 2). In the validation set, the model showed good discrimination (c statistic 0.84, 95% CI 0.82–0.87) and calibration (Hosmer–Lemeshow goodness-of-fit test, P = .34). If stress tests were avoided in patients in the validation sample with a sum score ≤ 0, the number of referrals would be reduced by 23.4%, yielding a negative predictive value of 98.8% (95% confidence interval 97.0–99.7%). Conclusion This novel prediction rule based on a combination of readily available clinical characteristics may be a valuable tool to decide whether stress testing can be reliably avoided in patients with acute chest pain and negative troponins.