EBQ:A prospective validation of the HEART score for chest pain patients at the emergency department

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Complete Journal Club Article
B.E. Backus, A.J. SixEmail the author A.J. Six, J.C. Kelder, M.A.R. Bosschaert, E.G. Mast, A. Mosterd, R.F. Veldkamp, A.J. Wardeh, R. Tio, R. Braam, S.H.J. Monnink, R. van Tooren, T.P. Mast, F. van den Akker, M.J.M. Cramer, J.M. Poldervaart, A.W. Hoes, P.A. Doevendans. "A prospective validation of the HEART score for chest pain patients at the emergency department". International Journal of Cardiology. 2013. 168:2153-2158.
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Clinical Question

  • Can the HEART score assess low risk chest pain patients and predict which patients are at risk for having 6 weeks of major adverse cardiac events (MACE)?

Conclusion

  • HEART score allows patients to be separated into a low, medium and high risk group.
  • Low HEART scores of 0-3 excludes short-term MACE in over 98% of patients and these patients might be most appropriate for outpatient follow up.
  • High HEART scores of 7-10 indicate a high likelihood of MACE and should prompt aggressive therapies.

Major Points

  • Low HEART scores defined as 0-3 have a 1.7% risk of MACE
  • MACE included- AMI, PCI, CABG, coronary angiography revealing procedurally correctable stenosis managed conservatively and death due to any cause
  • High HEART scores 7-10 might require more aggressive polices for MACE

Study Design

HEART score

  • History
    • Highly suspicious = 2
    • Moderately suspicious = 1
    • Slightly or non-suspicious = 0
  • ECG
    • Significant ST- depression = 2
    • Nonspecific repolarization disturbance = 1
    • Normal = 0
  • Age
    • ≥ 65 years = 2
    • 45-65 tears =1
    • ≤ 45 years = 0
  • Risk factors
    • ≥ 3 risk factors, or history of atherosclerotic disease = 2
    • 1 or 2 risk factors =1
    • No risk factors known = 0
  • Troponin
    • ≥ 3× normal limit =2
    • >1– <3× normal limit =1
    • ≤ Normal limit = 0
  • 10 hospitals in the Netherlands
  • Observational non-intervention study
  • troponin collected at moment of admission
  • ECG admission and was blindly reviewed and classified by cardiologists with 2 cardiologists reviewing and a third to settle any disagreements
  • TIMI, GRACE and HEART were automatically calculated without investigators interpreting results

Population

  • 2440 patients presenting from October 2008 – November 2009
  • 2433 patients evaluated with 45 lost to follow up with 2388 in study group
    • 1981 patients with no MACE
  • 407/2388 patients with MACE (17.0%)
    • 155/2388 AMI (6.4%)
    • 251/2388 PCI (10.5%)
    • 67/2388 CABG (2.8%)
    • 44/2388 conservative therapy (1.8%)
    • 16/2388 Death (0.7%)

Patient Demographics

  • mean age 60.6
  • Male gender 57.5%
  • DM 18.6%
  • Smoker 32.7%
  • Hypercholesterolemia 35.8%
  • Hypertension 43.3%
  • Family history 36.3%
  • Obesity 24.4%
  • Mean SBP/DBP 141.4/78.1
  • History of AMI 15.9%
  • History of CABG 10.2%
  • History of PCI 21.4%
  • History of stroke 4.7%
  • History of peripheral arterial disease 4.6%

Inclusion Criteria

  • patient admitted to the cardiac emergency department due to chest pain


Exclusion Criteria

  • patients presenting with dyspnea or palpitations
  • chest pain and significant ST segment elevations taken to coronary intervention room

Interventions

  • Observational study

Outcomes

Primary Outcome

  • Occurrence of major adverse cardiac events (MACE) within 6 weeks
  • HEART scores (0-3) in 36.4% of study population and 1.7% (15/870) had MACE
    • 9/870 had AMI
    • 9/870 had PCI
    • 3/870 had CABG
    • 1/870 died from suicide (20 year old- 7 days after chest pain presentation)
*HEART scores (4-6) in 46.1% of study population and 16.6% had MACE 
  • HEART scores (7-10) in 17.5% of study population and 50.1% had MACE
    • Looked at C-statistic for MACE: HEART 0.83>TIMI (0.75)>GRACE (0.70)

Secondary Outcomes=

  • Occurrence of AMI and death
    • 164/2388 with AMI (155/2388) or death (16/2388)
  • C-statistics for HEART TIMI and GRACE
  • ACS
    • 536/2388 with ACS in 3 months of presentation (501/536) 93.4% diagnosed during initial admission
  • Performance of coronary angiogram
    • 578/2388 had coronary angiogram with 93/578 (16.2%) during primary admission
      • 58/578 (16.2%) with normal coronaries
      • 104/578 (17.9%) with nonsignificant stenosis
      • 44/578 (7.6%) significant stenosis with conservative treatment
      • 361/578 (62.4%) significant stenosis with revascularization
      • 11/578 (1.9%) unclassified
  • HEART score compared to TIMI and GRACE scores
    • Looked at C-statistic for AMI or death HEART 0.82>GRACE (0.71)>TIMI (0.72)

Criticisms & Further Discussion

  • TIMI and GRACE don’t show which patients are low enough risks
  • HEART score allows us to send most patients home
  • identifies the high risk group in addition to the low risk patient groups
  • HEART score of 0-3 gets rid of 20% of low risk patients who can have outpatient management of the patients
  • HEART score of 7-10 has a risk for MACE of about 50 %
  • Each hospital had different troponin cut offs

External Links

See Also

Funding

References