Editorial
Clinical scales: Tools for the diagnosis of unstable angina
Escalas clínicas: una herramienta para el diagnóstico de angina inestable
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"apellidos" => "Romero-Moreno" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256517302898" "doi" => "10.1016/j.rce.2017.12.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256517302898?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887418300018?idApp=WRCEE" "url" => "/22548874/0000021800000002/v1_201802230423/S2254887418300018/v1_201802230423/en/main.assets" ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Clinical scales: Tools for the diagnosis of unstable angina" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "72" "paginaFinal" => "73" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Alquézar-Arbé, B. Lopez Barbeito" "autores" => array:2 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Alquézar-Arbé" "email" => array:1 [ 0 => "aalquezar@santpau.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "B." "apellidos" => "Lopez Barbeito" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servei Urgències, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Àrea D’Urgències, Hospital Clínic Provincial, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Miembro del grupo de trabajo del Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS) «Urgencias: procesos y patologías»" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Escalas clínicas: una herramienta para el diagnóstico de angina inestable" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Coronary artery disease is the leading cause of death worldwide, and its most typical presentation is acute coronary syndrome (ACS), which usually manifests as nontraumatic chest pain. ACS includes 3 entities<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a>: 1) acute myocardial infarction (AMI) with ST-segment elevation, whose diagnosis is established by the presence of specific electrocardiogram (ECG) abnormalities; 2) AMI without ST-segment elevation, whose diagnosis requires the demonstration of changes in concentration (both significant increases and decreases) in the serial measurements of cardiac troponin (cTn); and 3) unstable angina, in which myocardial ischemia occurs, which can be accompanied by ECG changes but with no significant changes in serial cTn readings. The diagnosis of this last entity is the most complex and usually requires additional studies such as stress testing and computed angiotomography.</p><p id="par0010" class="elsevierStylePara elsevierViewall">For most patients with an initial clinical suspicion of ACS, this entity is eventually ruled out,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> at the cost of extended observation times and various additional examinations. It is therefore essential to have strategies that enable clinicians to quickly differentiate patients with chest pain but no ACS from those who do have ACS.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Numerous strategies have been proposed to identify patients without ACS, strategies based on the medical history and additional examinations,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> combinations of biomarkers and risk scales<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> and even the implementation of imaging tests.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> In the study by Montero-Pérez et al.,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> published in this issue of <span class="elsevierStyleSmallCaps">Revista Clínica Española</span>, the authors proposed a clinical scale for the patient group with suspected ACS, in which the ECG and biomarkers are not conclusive. The aim of the scale is to discern which of these patients have unstable angina or pain of noncoronary origin. To this end, the study prospectively included 286 patients treated for chest pain in an emergency department of a tertiary hospital, with normal ECG results and no cTn increase. The final diagnosis was ACS in 103 patients (36%) and was conducted by consensus of at least 2 physicians, based on clinical data and additional tests, including cTn <span class="elsevierStyleSmallCaps">II</span>concentrations. Using multiple logistic regression, 3 predictors of ACS were identified: a history of coronary artery disease, hyperlipidemia and a score on the Geleijnse scale ≥6 points. The area under the receiver operating characteristic (ROC) curve for the final model was 0.90 (95% confidence interval [95% CI] 0.85–0.93). The authors proposed a decision point of 5 points for assigning the diagnosis of ACS, which achieved a sensitivity of 76.7% (95% CI 68–84%) and a specificity of 91.8% (95% CI 87–95%).</p><p id="par0020" class="elsevierStylePara elsevierViewall">Despite the interesting approach, there are several aspects of the study that deserve mention. Firstly, although assignment of the final diagnosis by consensus is the standard methodology in this type of study, a previous study showed that, despite an acceptable agreement (<span class="elsevierStyleItalic">k</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.79; 95% CI 0.73–0.85) between 2 groups of evaluators (one local and another central) in assigning the final diagnosis, up to 34% of the patients were reassigned in the central evaluation to a diagnostic category other than that performed in the local assessment.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> The lack of absolute agreement in the assignment is intrinsic to the methodology employed, but the final assignment of the conflicting cases, in one category or another, could affect the results and, as a result, their interpretation.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Secondly, the authors used a contemporary method for determining the cTn level, with a decision point of 0.30<span class="elsevierStyleHsp" style=""></span>ng/mL (corresponding to the value above the 99th percentile). Nevertheless, the European Society of Cardiology guidelines recommend the use of high-sensitivity cTn,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> an immunoassay that measures very low cTn concentrations with the analytical quality recommended in the successive definitions of AMI<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> (a coefficient of variation <10% in the concentration corresponding to the 99th percentile). This increased analytical sensitivity has 2 consequences. On one hand, it increases the diagnosis of AMI at the expense of a lower number of unstable angina cases.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> On the other, it increases the number of patients with high biomarker concentrations in situations other than AMI.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> Regardless of the patient's final diagnosis, high cTn values are associated with higher mortality in the follow-up,<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">12,13</span></a> although a strategy for these patients has not yet been determined.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Thirdly, based on the ROC curve values, the authors proposed a decision point for the use of the scale analyzed with diagnostic intent. Strategies with <1% of false negatives are considered useful for proposing discharges to home for patients with nontraumatic chest pain, without needing additional studies.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> For this reason, additional studies are needed to check the scale's validity and its inclusion in a decision-making algorithm.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion, the study by Montero-Pérez et al.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> shows the need to accurately identify patients with unstable angina. The study shows us a new tool based on clinical parameters, which is easy to implement and could facilitate the diagnosis and standardize the decision-making process.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Alquézar-Arbé A, Lopez Barbeito B. Escalas clínicas: una herramienta para el diagnóstico de angina inestable. 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