HEART Score
- The score has been derived and validated in an ED population and predicts 6 week adverse cardiac events[1][2]
- Low risk patients have a score 0-3 and have a less than 2% risk of MACE at 6 weeks.
Criteria
|
Point Value
|
History
|
Highly Suspicious |
+2
|
Moderately Suspicious |
+1
|
Slightly Suspicious |
0
|
ECG
|
Significant ST-depression |
+2
|
Non specific repolarisation disturbance |
+1
|
Normal |
0
|
Age
|
≥ 65 |
+2
|
45-65 |
+1
|
≤ 45 |
0
|
Risk Factors (Hypercholesterolemia, Hypertension, Diabetes Mellitus, Smoking,Obesity)
|
≥ 3 risk factors or history of atherosclerotic disease |
+2
|
1-2 risk factors |
+1
|
No risk factors known |
0
|
Troponin
|
≥ 3× normal limit |
+2
|
1-3× normal limit |
+1
|
≤ normal limit |
0
|
- 0-3: 2.5% risk of adverse cardiac event. Patient's can be discharged with follow-up.
- 4-6: 20.3% risk of adverse cardiac event. Patients should be admitted to the hospital for trending of troponin and provocative testing.
- ≥7: 72.7% risk of adverse cardiac event, suggesting early invasive measures with these patients and close coordination with inpatient cardiology
New Vancouver Chest Pain Rule
- Useful for screening patient with low risk for ACS
- The old Vancouver chest pain rule was not properly validated[3][4] [4]
- The new rule was validated in 2014 on 1635 patients and published in 2014[5]
- With high sensitivity troponins the sensitivity is 99.1% (95% CI 97.4-99.7), & specificity is 16.1 (95% CI 14.2-18.2)
- With sensitive troponin-I the sensitivity was 98.8% (97.0-99.5), & specificity of 15.8 (13.9-17.9)
Algorithm
- Is the same for c-TnI assay and hs-TnI assay but sensitivity differences by a percentage point
- Is there an abnormal ECG, positive troponin at 2 hrs or prior ACS nitrate use?
- If Yes to any then no early discharge
- Does palpation reproduce the pain?
- If Yes then early discharge
- Age ≥50, or does pain radiate to neck, jaw, or left arm?
- If Yes then no early discharge
- If answer is No to all of the above stepwise questions then the patient can have early discharge with close follow-up for further provocative testing
Likelihood That Signs/Symptoms Represent ACS due to CAD
Feature
|
High Likelihood (any of the following)
|
Intermediate Likelihood (absence of high-likelihood features and presence of any of the following)
|
Low Likelihood (absence of high- or intermediate-likelihood features but may have)
|
History
|
Chest or left arm pain or discomfort as chief symptom reproducing prior documented angina
|
Chest or left arm pain or discomfort as chief symptom
|
Probable ischemic symptoms in absence of any of the intermediate-likelihood characteristics
|
Known history of coronary artery disease, including myocardial infarction
|
Age >70 y old
|
Recent cocaine use
|
Male sex
|
Diabetes mellitus
|
Examination
|
Transient mitral regurgitation murmur, hypotension, diaphoresis, pulmonary edema, or rales
|
Extracardiac vascular disease
|
Chest discomfort reproduced by palpation
|
ECG
|
New, or presumably new, transient ST-segment deviation (1 mm or greater) or T-wave inversion in multiple precordial leads
|
Fixed Q waves
|
T-wave flattening or inversion <1 mm in leads with dominant R waves
|
ST depression 0.5–1.0 mm or T-wave inversion >1 mm
|
Normal ECG
|
Cardiac markers
|
Elevated cardiac troponin I, troponin T, or MB fraction of creatine kinase
|
Normal
|
Normal
|
Short-Term Risk of Composite Outcome
Composite Outcome: Death or Nonfatal Myocardial Infarction by Risk Stratification in Patients with Unstable Angina
Feature
|
High Likelihood (at least one of the following features must be present)
|
Intermediate Likelihood (no high-risk feature, but must have one of the following)
|
Low Likelihood (no high- or intermediate-risk feature, but may have any of the following)
|
History
|
Accelerating tempo of ischemic symptoms in preceding 48 h
|
Prior myocardial infarction, peripheral or cerebrovascular disease, or coronary artery bypass grafting; prior aspirin use
|
—
|
Character of the pain
|
Prolonged ongoing (>20 min) rest pain
|
Prolonged (>20 min) rest angina, now resolved, with moderate or high likelihood of CAD
|
Increased angina frequency, severity, or duration
|
Rest angina (>20 min) or relieved with rest or sublingual nitroglycerin
|
Angina provoked at a lower threshold
|
New-onset angina with onset 2 wk to 2 mo before presentation
|
Nocturnal angina
|
New-onset or progressive Canadian Cardiology Society Class III or IV angina in the past 2 wk without prolonged (>20 min) rest pain but with intermediate or high likelihood of CAD;
|
|
Clinical findings
|
Pulmonary edema, most likely due to ischemia
|
Age >70 y old
|
Chest discomfort reproduced by palpation
|
New or worsening mitral regurgitation murmur
|
S3 or new/worsening rales
|
Hypotension, bradycardia, tachycardia
|
Age >75 y old
|
ECG
|
Angina at rest with transient ST-segment changes >0.5 mm
|
T-wave changes, pathologic Q waves, or resting ST depression <1 mm in multiple lead groups (anterior, inferior, lateral)
|
Normal or unchanged ECG
|
Bundle-branch block, new or presumed new
|
Sustained ventricular tachycardia
|
Cardiac markers
|
Elevated cardiac TnT, TnI, or CK-MB (e.g., TnT or TnI >0.1 nanogram/mL)
|
Slightly elevated cardiac TnT, TnI, or CK-MB (e.g., TnT >0.01 but <0.1 nanogram/mL)
|
Normal
|
TIMI Risk Stratification Score
NSTEMI TIMI Score[6]
- Used to estimate percent risk of all-cause mortality, new/recurrent MI, or need for revascularization at 14 days
- Age >65 yrs (1 point)
- Three or more risk factors for coronary artery disease: (1 point)
- family history of coronary artery disease
- hypertension
- hypercholesterolaemia
- diabetes
- current smoker
- Use of aspirin in the past 7 days (1 point)
- Significant coronary stenosis (stenosis >50%) (1 point)
- Severe angina (e.g., >2 angina events in past 24 h or persisting discomfort) (1 point)
- ST-segment deviation of ≥0.05 mV on first ECG (1 point)
- Increased troponin and/or creatine kinase-MB blood tests (1 point)
TIMI Risks
points
|
% risk of mortality, MI, or need for revascularization
|
0 |
5%
|
1 |
5%
|
2 |
8%
|
3 |
13%
|
4 |
20%
|
5 |
26%
|
6 |
41%
|
See Also
References
- ↑ Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008 Jun;16(6):191-6.PMID 18665203
- ↑ Backus BE, Six AJ, Kelder JC, Bosschaert MA. et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013 Oct 3;168(3):2153-8 PMID 2346525
- ↑ Jalili M. Validation of the Vancouver Chest Pain Rule: a prospective cohort study. Acad Emerg Med. 2012 Jul;19(7):837-42.
- ↑ 4.0 4.1 Christenson J. A clinical prediction rule for early discharge of patients with chest pain. Ann Emerg Med. 2006 Jan;47(1):1-10.
- ↑ Cullen L et al. The new Vancouver Chest Pain Rule using troponin as the only biomarker: an external validation study. Am J Emerg Med. 2014 Feb;32(2):129-34
- ↑ Antman, Elliot et al. The TIMI Risk Score for Unstable Angina/Non–ST Elevation MI A Method for Prognostication and Therapeutic Decision Making. JAMA. 2000;284(7):835-842. doi:10.1001/jama.284.7.835. PDF