“So what’s the dispo?” The looming question over every Emergency Department patient. Your 63-year-old patient with chest pain has had two normal EKGs and troponins, yet something in your gut is telling you that maybe this person needs admission. But is your gut feeling good enough to warrant admission? Is there any risk stratification tool out there to help you decide? And if so, is it useful and valid? Here, we discuss a landmark article in Emergency Medicine: “A Prospective Validation of the HEART Score for Chest Pain Patients in the Emergency Department”.
What is the HEART Score?
The HEART Score was created to risk-stratify patients presenting to the emergency department with chest pain for major adverse cardiac events (MACE) at 30 days.
MACE: Composite of acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft, and death.
Five factors (each scored 0-2): History, Electrocardiogram, Age, Risk factors, Troponin
MACE at 30 days is 0.9-1.7% if low risk (score = 0-3), 12-16.6% if moderate risk (score = 4-6), and 50-65% if high risk (score = 7-10)
Is the heart score validated in the ED and how should we be using it?
Goal of the study:
To create a prospective validation of the HEART score.
Methods:
2,440 patients who presented with chest pain (not dyspnea or palpitations) to the ED of ten participating hospitals in The Netherlands.
The HEART score was assessed as soon as the first lab results and ECG were obtained, data acquired more than 1 hour after presentation were ignored for score calculations
Primary endpoint: occurrence of major adverse cardiac events (MACE) within 6 weeks.
Secondary endpoints: occurrence of AMI and death, ACS, PCI, the performance of coronary angiogram.
Results:
Scores 0-3: MACE occurred in 1.7%
Scores 4-6: MACE occurred in 16.6%
Scores 7-10: MACE occurred in 50.1%
Overall 407 patients (17.0%) were diagnosed with MACE within 6 weeks
AMI was diagnosed in 155 patients (6.4%)
251 patients (10.5%) underwent PCI
67 patients (2.8%) had a CABG
44 patients (1.8%) had coronary angiography revealing procedurally correctable stenosis managed conservatively
Sixteen patients (0.7%) died within 6 weeks after presentation.
13 patients died of a cardiac cause: 1 patient in the low-risk HEART group, 5 in the intermediate-risk HEART group and 7 in the high-risk HEART group.
3 of these 16 patients died due to non-cardiovascular causes, including the one in the low-risk HEART group
Was also compared to TIMI and GRACE scores:
The c-statistic of the HEART score (0.83) was significantly higher than the c-statistic of TIMI (0.75) and GRACE (0.70) respectively (p<0.0001)
Note: c-statistic measures how well a model can rank patients from high to low risk
Conclusion:
Low HEART scores (0-3) exclude short-term MACE with >98% certainty. In correlation with your clinical judgement, these patients can be discharged with outpatient follow-up.
The HEART Score performs better than TIMI and GRACE. The HEART Score was specifically designed for the much broader chest pain population of the emergency department.
Limitations:
The study was performed on a patient population in the Netherlands.
Each ED in the study had different cut-off values for positive troponins.
No comparison of HEART Score to clinical gestalt.
Disclaimer:
The HEART Score is a decision aid, not a rule to live by. It should always be used in conjunction with your medical knowledge.
Reference Article: Backus BE, Six AJ, Kelder JC, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013;168(3):2153-2158. doi:10.1016/j.ijcard.2013.01.255
Authored by Taylor Wahrenbrock, MD.