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Validation of a triage flowchart to rule out acute coronary syndrome
  1. Beatriz López1,2,
  2. Miquel Sánchez1,2,
  3. Ernest Bragulat1,2,
  4. Sònia Jiménez1,2,
  5. Blanca Coll-Vinent1,2,
  6. Mar Ortega1,2,
  7. Elisenda Gómez-Angelats1,2,
  8. Òscar Miró1,2
  1. 1Emergency Department, Hospital Clínic de Barcelona, Barcelona, Spain
  2. 2“Urgencias: procesos y patologías”, IDIBAPS, Barcelona, Spain
  1. Correspondence to Dr Miquel Sánchez, Emergency Department, Hospital Clínic de Barcelona, Villarroel 170, 08036 Barcelona, Catalonia, Spain; msanchez{at}


Objective To validate a triage flowchart to rule out acute coronary syndrome (ACS) in chest pain patients attending the emergency department (ED).

Methods An observational cohort study of consecutive patients. In all cases, a previously derived five-step triage flowchart (age ≤40 years, absence of diabetes, not previously known coronary artery disease, non-oppressive and non-retrosternal pain) was applied. Patients meeting all five discriminators were grouped as ‘five-step triage non-ACS’, the rest as ‘five-step triage ACS’. The same strategy was used with a four-step model (without age ≤40 years). After ED study and 1-month follow-up, patients were definitively classified as ‘true ACS’ or ‘true non-ACS’. Validity indexes and receiver operating characteristics curves were calculated.

Results 4231 patients were included: 918 (21.7%) were ‘true ACS’, 3303 (78.1%) ‘true non-ACS’; 10 (0.2%) were lost to follow-up. The five-step triage flowchart classified 4000 (94.8%) as ‘triage ACS’ and 221 (5.2%) as ‘triage non-ACS’; none of the latter was ‘true ACS’. The four-step model classified 3194 (75.6%) as ‘triage ACS’ and 1027 (24.4%) as ‘triage non-ACS’. A ‘true ACS’ was seen in 26 patients from the latter group. Accordingly, five-step triage flowchart specificity and positive predictive value (PPV) to rule out ACS were 100% (95% CI 100% to 100%). For the four-step model specificity and PPV were 97% (95% CI 96% to 98%).

Conclusion The five-step triage flowchart identifies chest pain patients without an ACS. However, only 5% of these patients meet these five criteria. A simpler model allows greater patient inclusion but a higher risk of misclassification of true ACS.

  • Acute coronary syndrome
  • cardiac care
  • chest pain
  • chest pain unit
  • emergency care systems
  • emergency department
  • prediction
  • trauma

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  • Funding OM received grant support from the Instituto de Salud Carlos III in 2009.

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval This study was conducted with the approval of the hospital's institutional review broad.

  • Provenance and peer review Not commissioned; externally peer reviewed.