Aplicación de las escalas de estratificación del riesgo en el diagnóstico de los síndromes coronarios agudos / Implementation of risk stratification scales in the diagnosis of acute coronary syndromes

Resumen Introducción: El dolor torácico es uno de los principales motivos de consulta en el servicio de urgencias. Diferentes escalas de riesgo han sido evaluadas en los pacientes con dolor torácico. El objetivo del presente estudio es comparar el desempeño diagnóstico de las escalas de riesgo en los pacientes con dolor torácico y sospecha de síndrome coronario agudo. Métodos: Estudio de pruebas diagnósticas que incluyó pacientes mayores de 18 años con dolor torácico y sospecha de síndrome coronario agudo. El estándar de referencia fue alguna prueba de estratificación coronaria invasiva o no invasiva y la prueba índice la constituyó la puntuación de las escalas de riesgo TIMI, GRACE, CARdiac, Florencia, Sanchis y HEART. Se calcularon las características operativas para diferentes puntos de corte y se compararon las áreas bajo la curva ROC. Resultados: Se incluyeron 249 pacientes, 143 (57,4%) fueron de sexo masculino, 65,3 años de edad media; 73 (29,3%) fueron anginas inestables, 79 (31,7%) presentaron infartos agudos de miocardio sin elevación del ST y a 97 (39%) se les descartó la enfermedad coronaria. Las escalas HEART y TIMI mostraron el mejor rendimiento diagnóstico con un área bajo la curva de 0,75 (IC del 95% 0,69-0,81) y 0,71 (IC del 95% 0,65-0,77). Las áreas bajo la curva de Florencia, CARdiac, GRACE, y Sanchis fueron 0,64 (IC 95% 0,57-0,71), 0,63 (IC 95% 0,57-0,69), 0,62 (IC 95% 0,55-0,69), y 0,62 (IC 95% 0,55-0,69), respectivamente. Conclusiones: En una población de pacientes con alta probabilidad para el síndrome coronario agudo, las escalas HEART y TIMI mostraron una mayor capacidad para discriminar el diagnóstico del síndrome coronario agudo.

Abstract Introduction: Chest pain is one of the main reasons for consultation in the emergency room. Several risk scales have been assessed in patients with chest pain. The motivation of this study is to compare the diagnostic performance of risk scales in patients with chest pain and suspicion of acute coronary syndrome. Methods: Study of diagnostic tests that included patients over the age of 18 with chest pain and suspicion of acute coronary syndrome. The reference standard was an invasive or noninvasive coronary stratification test and the index test consisted of the score in risk scales TIMI, GRACE, CARdiac, Florencia, Sanchis and HEART. Operative characteristics for different cut points were calculated and the areas under the ROC curve were compared. Results: The study included 249 patients, of whom 143 (57.4%) were male, average age was 65.3 years; 73 (29.3%) were unstable anginas; 79 (31.7%) showed acute myocardial infarctions without ST elevation and for 97 (39%) coronary disease was ruled out. HEART and TIMI scales revealed the best diagnostic performance with a low area under the curve of 0.75 (CI of 95% 0.69-0.81) and 0.71 (CI of 95% 0.65-0.77). Areas under the curve for Florencia, CARdiac, GRACE, and Sanchis were 0,64 (CI 95% 0.57-0.71), 0.63 (CI 95% 0.57-0.69), 0.62 (CI 95% 0.55-0.69), and 0.62 (CI 95% 0.55-0.69), respectively. Conclusions: In a patient population with high probability for acute coronary syndrome, HEART and TIMI scales showed a greater ability to discriminate the diagnosis of acute coronary syndrome.

Incidence and Risk Factors for Early Acute Kidney Injury in Nonsurgical Patients: A Cohort Study.

Introduction. Detecting acute kidney injury (AKI) in the first days of hospitalization could prevent potentially fatal complications. However, epidemiological data are scarce, especially on nonsurgical patients. Objectives. To determine the incidence and risk factors associated with AKI within five days of hospitalization (EAKI). Methods. Prospective cohort of patients hospitalized in the Internal Medicine Department. Results. A total of 16% of 400 patients developed EAKI. The associated risk factors were prehospital treatment with nephrotoxic drugs (2.21 OR; 95% CI 1.12-4.36, p = 0.022), chronic kidney disease (CKD) in stages 3 to 5 (3.56 OR; 95% CI 1.55-8.18, p < 0.003), and venous thromboembolism (VTE) at admission (5.05 OR; 95% CI 1.59-16.0, p < 0.006). The median length of hospital stay was higher among patients who developed EAKI (8 [IQR 5-14] versus 6 [IQR 4-10], p = 0.008) and was associated with an increased requirement for dialysis (4.87 OR 95% CI 2.54 to 8.97, p < 0.001) and in-hospital death (3.45 OR; 95% CI 2.18 to 5.48, p < 0.001). Conclusions. The incidence of EAKI in nonsurgical patients is similar to the worldwide incidence of AKI. The risk factors included CKD from stage 3 onwards, prehospital treatment with nephrotoxic drugs, and VTE at admission. EAKI is associated with prolonged hospital stay, increased mortality rate, and dialysis requirement.