Which clinical scoring system should we use for the evaluation of chest pain in the Emergency Department? A review

Many clinical prediction rules and scoring systems have been developed to predict Acute Coronary Syndrome in-patient with chest pain (CP) in Emergency Department. In this review we check and compare the level of validity and reliability of the TIMI (thrombolysis in myocardial infarction); HEART (history, ECG, age, risk factors, troponin); GRACE (global registry of acute coronary events). We used as eligibility criteria: all studies, reviews and meta-analysis on validity and reliability of clinical score systems for CP conducted on all ages of patients in all languages. The selection of articles included in the review was performed according to PRISMA guidelines. We collected one systematic review, one meta-analysis and eleven studies. The HEART score showed the best validity in predicting the outcomes tested with a mean AUROC value of 0.86 (range 0.83- 0.88); the GRACE score showed a good validity: mean AUROC value=0.78 (range 0.70-0.82); the TIMI a moderate validity: mean AUROC=0.67 (range 0.42-0.79). The only included study on the reliability showed that the TIMI score had a poor to moderate reliability: weighted kappa range=k= 0.30-0.43. In conclusion, in this review the HEART and GRACE scores showed the best validity in predicting acute coronary syndromes and major cardiac events. To our knowledge there is only one study on the reliability of TIMI score that showed a poor to moderate inter-rater reliability. There are no studies on the reliability of other score systems.