Clinical scores for risk stratification of chest pain patients in the emergency department: an updated systematic review

Nan Liu, Janson Cheng Ji Ng, Chu En Ting, Jeffrey Tadashi Sakamoto, Andrew Fu Wah Ho, Zhi Xiong Koh, Pin Pin Pek, Swee Han Lim, Marcus Eng Hock Ong


Chest pain is among the most common complaint presenting to the emergency departments (EDs) worldwide. The etiology of chest pain can range from benign to life threatening causes. Therefore, it is crucial to stratify chest pain patients based on risk for development of major adverse cardiac events (MACE) in order to provide effective care and prevent overutilization of resources. Over the years, many risk stratification tools have been developed, among which, the History, Electrocardiogram (ECG), Age, Risk factors, and initial Troponin (HEART), Thrombolysis in Myocardial Infarction (TIMI), and Global Registry of Acute Coronary Events (GRACE) scores are the most widely used. This systematic review aims to provide an up-to-date summary of the latest studies on clinical scores for risk stratification of chest pain patients presenting to the ED. We conducted a search of the literature in online databases PubMed and Embase. Our search was limited to articles published between 01 January 2012 and 25 September 2017. Studies were eligible for inclusion if the reported clinical scores were used for risk stratifying ED chest pain patients. Systematic reviews, meta-analyses, case reports, and letters to the editor were excluded. Two independent reviewers screened the titles, abstracts, and full articles for the inclusion of studies. We retrieved a total of 514 articles from both databases and included 29 studies in this systematic review. The articles covered studies from over 20 countries, where more than 20 different risk scores and scoring methods were investigated. Among the various risk scores, the HEART, TIMI, GRACE, and heart rate variability (HRV)-based scores were the most widely implemented and discussed. We found that the HEART score was generally the top performer in identifying chest pain patients at high or low risk of developing MACE. Most HRV-based scoring methods had comparable performance to the HEART score while benefiting from faster score calculation without a need for laboratory testing. This could potentially be useful in accelerating existing chest pain protocols in the ED setting.