A Practical Approach With Outcome for the Prognostic Assessment of NonST-Segment Elevation Chest Pain and Normal TroponinJuan Sanchis, MD, PhDa,*, Vicent Bod, MD, PhDa, Julio Nez, MDa, Mara Jos Bosch, MDa, Vicente Bertomeu-Gonzlez, MDa, Luciano Consuegra, MDa, Enrique Santas, MDa, Cristina Gmeza, Xavier Bosch, MD, PhDb, Francisco Javier Chorro, MD, PhDa, and ngel Llcer, MD, PhDaPatients with nonST-elevation chest pain constitute a heterogeneous population. Our aim is to compare the outcome of patients with chest pain, nonST-segment deviation, and normal troponin, categorized using a risk score, with that of patients with ST depression or troponin increase. A total of 1,449 patients with nonST-elevation chest pain were evalu- ated. A validated risk score (using pain characteristics and risk factors) was applied to patients without ST depression or troponin increase. Accordingly, 4 risk categories weredefined: group 1, no troponin increase, no ST depression, and risk score 3 points (n ? 158); group 3, no troponin increase, ST depression (n ? 106); and group 4, troponin increase (n ? 552). Median follow-up was 26 months, and the end point was death or myocardial infarction. Group 1 experienced fewer events at 30 days (1.7%, p ? 0.0001) and long-term follow-up (9.4%, p ? 0.0001) than groups 2 (10.8% and 26%), 3 (6.6% and 30%), and 4 (9.5% and 25%). Kaplan-Meier curves overlapped among groups 2, 3, and 4, whereasgroup 1 showed a flatter curve (p ? 0.0001). Using multivariate analysis, risk group (group 1 vs remaining groups) predicted 30-day (p ? 0.0003) and long-term (p ? 0.0001) outcome. There were no differences among groups 2, 3, and 4. In conclusion, application of a riskscore to patients without troponin increase or ST deviation identified a high-risk group with prognosis similar to that of patients with troponin increase or ST depression andaffords a practical classification for the full spectrum of nonST-elevation chest pain. 2007 Elsevier Inc. All rights reserved. (Am J Cardiol 2007;99:797801)Recently, we described a new risk score for the stratification of patients with chest pain, nonST-segment deviation, and normal troponin concentrations.1The purpose of the present study is to compare the outcome of these patients with nonST-segment deviation and normal troponin, catego- rized using the score, with that of well-established high-riskpatients defined by ST-segment depression or troponin in- crease. This analysis will help locate the population of patients with chest pain without ST-segment deviation or troponin increase in the full spectrum of patients with non ST-segment elevation acute chest pain.MethodsFrom January 15, 2001, to April 1, 2005, a total of 1,449 consecutive patients came to the emergency department ofour hospital with chest pain of possible coronary origin. The inclusion criterion was the clinical diagnosis of chest pain of possible coronary origin, established by the cardiologist on duty. ST-segment elevation, new left branch bundle block, and history of nonischemic heart disease were exclusion criteria. Patients with heart failure at admission also were excluded because they constitute a high-risk population for which the initial evaluation and management differ from that of patients presenting with pure chest pain. All patients were evaluated using a chest pain unit protocol imple- mented in our institution. This protocol is explained else- where.16In brief, it consists of evaluation of clinical his- tory (assessment of characteristics of chest pain presentation and risk factors), electrocardiogram (ST-segment depres- sion considered if ?1 mm), serial troponin I determination (on arrival and 8 and 12 hours after pain onset), and early exercise testing in eligible patients. Troponin I was mea- sured using standard methods (Immulite assay, Diagnostic Products Corp., Los Angeles, California), and positive and negative values for myocardial infarction were assigned according to European Society of Cardiology/American College of Cardiology recommendations for biochemical marker evaluation.7Management: Patients with ST-segment depression or troponin increase were directly hospitalized and treated with aspirin, enoxaparin, and?blockers (unless contraindi- cated). Indication for invasive study was left to the discre- tion of the attending physician. Cardiac catheterizationaServei de Cardiologia, Hospital Clnic Universitari, Universitat deValncia; andbServei de Cardiologia, Hospital Clnic i Provincial, Barce-lona, Spain. Manuscript received August 16, 2006; revised manuscript received and accepted October 9, 2006. This work was supported by the Instituto de Salud Carlos III (Spanish Public Health System, Spain) under the grant RECAVA-FIS and by the Fundacin Espaola del Corazn (Sociedad Espaola de Cardiologa, Spain) under the grant “Beca para Investigacin Clnica y Bsica en Cardiologa 2005”, Madrid, Spain. *Corresponding author: Tel.: 34-96-386-2658; fax: 34-96