Background: Guidelines recommend the use of risk scores to select patients for further investigation after myocardial infarction has been ruled out but their utility to identify those with coronary artery disease is uncertain. Methods: In a prospective cohort study, patients with intermediate high-sensitivity cardiac troponin I concentrations (5 ng/L to sex-specific 99th percentile) in whom myocardial infarction was ruled out were enrolled and underwent coronary computed tomography angiography (CCTA) after hospital discharge. HEART, EDACS, GRACE, TIMI, SCORE2 and PCE risk scores were calculated and the odds ratio (OR) and diagnostic performance for obstructive coronary artery disease determined using established thresholds. Results: In 167 patients enrolled (64±12 years, 28% female), 29.9% (50/167) had obstructive coronary artery disease. The odds of having obstructive disease was increased for all scores with the lowest and highest increase observed for an EDACS score ≥16 (OR 2.2 [1.1-4.6]) and a TIMI risk score ≥1 (OR 12.9 [3.0-56.0]), respectively. The positive predictive value (PPV) was low for all scores but was highest for a GRACE score >88 identifying 39% as high-risk for a PPV of 41.9% (30.4-54.2%). The negative predictive value (NPV) varied from 77.3% to 95.2% but was highest for a TIMI score of 0 identifying 26% as low-risk for a NPV of 95.2% (87.2-100%). Conclusions: In patients with intermediate cardiac troponin concentrations in whom myocardial infarction has been ruled out, clinical risk scores can help identify patients with and without coronary artery disease, but the performance of established risk thresholds requires optimisation for this purpose.

Dr Williams has received speaker fees from Cannon Medical Systems, Siemens Healthineers and Novartis. Dr Mills reports research grants awarded to the University of Edinburgh from Abbott Diagnostics, Siemens Healthineers and Roche Diagnostics outside the submitted work, and honoraria from Abbott Diagnostics, Siemens Healthineers, Roche Diagnostics, LumiraDx and Psyros Diagnostics. All other authors have no interests to declare.

Clinical Trial Registration: https://clinicaltrials.gov/study/NCT04549805 ID: NCT04549805

Dr Williams is supported by the British Heart Foundation (FS/ICRF/20/26002). Dr Mills is supported by a Chair Award (CH/F/21/90010), Programme Grant (RG/20/10/34966), and Research Excellence Award (RE/18/5/34216) from the British Heart Foundation. Dr Lee is supported by a British Heart Foundation Clinical Research Training Fellowship (FS/18/25/33454).

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