Rethinking risk stratification in acute chest pain: limited value of HEAR and GRACE scores in the high-sensitivity troponin era from a brazilian cohort

Risk stratification is central to the management of acute chest pain, guiding early decision-making and resource allocation. Despite major advances in biomarkers, clinical scores such as HEAR and GRACE remain guideline-endorsed tools for acute coronary syndrome (ACS) risk prediction. However, both were developed in the conventional troponin era and rely on subjective variables, whose incremental value in the context of high-sensitivity cardiac troponins (hs-cTn) is uncertain. Whether these scores still enhance early prognostic assessment when hs-cTnI is available in real-world, high-risk populations remains unclear.

To determine whether admission hs-cTnI outperforms HEAR and GRACE for prognostic assessment and whether troponin alone is sufficient as a stand-alone risk tool in suspected ACS.

A pragmatic, prospective, single-center cohort study was conducted at a tertiary cardiology hospital in Brazil between March and November 2024. Adults (≥18 years) presenting with chest pain suspicious for ACS were included if managed under institutional 0/1-hour or single rule-out hs-cTnI protocols. Exclusion criteria were ST-elevation MI, myopericarditis, pulmonary embolism, or non-ischemic chest pain. The primary endpoint was a composite of myocardial infarction (MI) or all-cause death; the secondary endpoint included MI, death, or revascularization. Hs-cTnI was measured using a validated high-sensitivity troponin I immunoassay routinely employed in the institutional laboratory.. Discrimination was assessed by ROC analysis, and independent predictors were identified with multivariable logistic regression adjusting for HEAR and GRACE.

A total of 681 patients were analyzed (mean age 64.2 ± 11 years, 63% male), with a high prevalence of known coronary artery disease (63.5%). For the primary endpoint (MI or death), hs-cTnI showed excellent discrimination (AUC 0.917), clearly outperforming HEAR (0.592) and GRACE (0.643). For the secondary endpoint (MI, death, or revascularization), AUCs were 0.803 for hs-cTnI, 0.631 for HEAR, and 0.605 for GRACE. In multivariable analysis, only hs-cTnI remained an independent predictor of MI/death (OR 1.01, 95% CI 1.01–1.01, p<0.001). Neither HEAR (p=0.110) nor GRACE (p=0.119) retained statistical significance, confirming that clinical scores add no incremental prognostic value once hs-cTnI is incorporated.

In this real-world Brazilian cohort, baseline hs-cTnI markedly outperformed HEAR and GRACE for predicting MI and death. Troponin alone provided accurate, early risk discrimination, challenging the routine use of traditional clinical scores in the high-sensitivity troponin era and showing that faster and safer triage can be achieved using troponin alone.

Multivariable logistic regression models