Article Review by Dr Regan Tuder
Can ED patients with nonspecific chest pain concerning for NSTEMI be risk stratified for MACE?
- Retrospective study
- 3 months period in 2006 taken from 120 ED patients in a single 200-bed community hospital in the Netherlands with CC of chest pain
- Age 61.2 +/-15.4 years old, 73M/49F. Race was not noted, but area around the hospital was 95% Caucasian
- Troponins <0.04 were not repeated
- Patients were followed for 423 +/- 106 days for MACE
- Highly suspicious 2
- Moderately suspicious: 1
- Slightly/non suspicious: 0
- Significant ST-depressions: 2
- Nonspecific repolarization disturbance: 1
- Normal: 0
- >65: 2
- 46-64: 1
- <45: 0
- Risk Factors
- >3 or hx of atherosclerotic disease: 2
- 1-2 risk factors: 1
- No known risk factors: 0
- >3x normal limit: 2
- 1-3x normal limit: 1
- < Normal limit: 0
- Low (<2%) risk of MACE
- Moderate (12-16%) risk of MACE. Suitable for observation & stress testing
- High (50-65%) risk of MACE. Admit for further testing
There have been 3 separate validation studies, each with MACE rate <2%.
The first was conducted in 2012 in the Netherlands with 2440 patients who presented to 10 different cardiac emergency departments. HEART score was calculated immediately after EKG and lab results obtained. Primary endpoint was MACE within 6 weeks. 17% of the total (407) were diagnosed with MACE within 6 weeks, and 16 patients died. Mean time to MACE was 5.6 days.
- Low risk boundary was set to MACE <5%, which corresponded to HEART score 0-3 and represented 36.4% of patients. 6 week MACE occurred in 1.7%, with one death.
- Intermediate risk boundaries were 5-40%, representing 46.1% of patients and a 16.6% 6 week MACE, HEART score 4-6
- High risk boundary was over 40%, representing 17.5% of the population with a 50.1% 6 week MACE, HEART score 7-10
the HEART score is a simple metric that can be used at bedside as a quick predictor of outcome for chest pain patients, excluding MACE in more than 1/3 of patients with >98% certainty, and suggesting more aggressive interventions with patients in the high risk group.
A randomized trial was completed in the US (NC academic) in 2012-2014 comparing the HEART Pathway and usual care in a real-time study.
- 282/5003 patients without ST elevation on EKG were randomized to HEART or usual care arms.
- Primary outcome: objective cardiac testing (stress or angiography)
- Secondary outcome: length of stay, early discharge, MACE assessed at 30 days
- The participants were broken down by race, gender, ethnicity, risk factors and insurance status
- 46.8% in the HEART arm were low risk, compared to 26% in the usual care arm.
- 56.7% had objective cardiac testing within 30 days, compared to 68.8% in the usual care arm.
- Early discharge was 39.7% in the HEART arm v. 18.4% with usual care.
- Median LOS in the HEART arm was 12 hours shorter.
- No early discharge patients in either group had a MACE. There was not an increase in cardiac related return ED visits in the HEART group.
Adherent use of the HEART score substantially increases early discharge, significantly reduces length of stay, and reduces objective cardiac testing without adversely affecting patient safety.
- Reliance on physician gestalt introduces a subjective element. The HEART score does not account for non-typical chest pain history.
- Many physicians do not always follow the HEART guidelines and still admit low-risk patients to observation/inpatient.
- There is significant discordance between emergency physician HEART scores, and those calculated by cardiologists.
- Physicians with more experience give patients higher HEART scores than those with <5 years experience.
- Risk factors may not be known to the patient and therefore may not be included in the score.
- EKG changes can by dynamic. The HEART score does not specify the need for a repeat EKG.
- Follow-up may be difficult for some patients, not ideal for borderline scores. Shared decision making is a key component of HEART.
Average savings of $216/patient. Over the estimated 8-10 million patients with undifferentiated chest pain per year in the US, following the HEART pathway could result in more than $2 billion in savings
- Use of the HEART pathway increases early discharge/decreases admission for chest pain by 21% with NPV for MACE >99% versus usual care
- Use of the HEART pathway decreases further cardiac testing by 12.1% and length of stay by 12 hours
- Back to those 9750 cases per year at TJUH: adherence to HEART score could save 117,000 hours and $2,106,000
- Pope, JH, MD, et al. Missed diagnosis of acute cardiac ischemia in the emergency department. NEJM 2000;342:1163-1170
- Six, AJ, et al. Chest pain in the emergency room: value of the HEART score. Netherlands Heart Journal, Volume 16, Number 6, June 2008
- Backus, BE, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. International Journal of Cardiology 168 (2013) 2153-2158.
- Mahler, SA, MD, MS, et al. The HEART pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circulation: Cardiovascular Quality and Outcomes 8 (2015):195-203.
- Long, B, et al. An end-user’s guide to the HEART score and pathway, American Journal of Emergency Medicine (2017), http://dx.doi.org/10.1016/j.ajem.2017.03.047
- Riley, RF, MD, MS et al. Cost analysis of the History, ECG, Age, Risk factors, and initial Troponin (HEART) Pathway randomized control trial. American Journal of Emergency Medicine 35 (2017) 77–81
- Poldevaart, JM et al. Effect of using the HEART score in patients with chest pain in the emergency department: a stepped-wedge, cluster randomized trial. Annals of Internal Medicine 166 (2017) 10: 689-697
- Poldevaart, JM et al. Comparison of the GRACE, HEART and TIMI score to predict major adverse cardiac events in chest pain patients at the emergency department. International Journal of Cardiology 227 (2017) 656-661.
- Long, Brit, MD, et al. An end-user’s guide to the HEART score and pathway. American Journal of Emergency Medicine (2017) Article in press.
- Long, Brit, MD, et al. Best Clinical Practice: Current controversies in the evaluation of low-risk chest pain with risk stratification aids, part 2. The Journal of Emergency Medicine 52 (2017) 1:43-51
- Documentation of HEART score discordance between emergency physician and cardiologist evaluations of ED patients with chest pain. American Journal of Emergency Medicine 35 (2017) 132-135.
- Marchick, MR, MD, et al. Comparison of 3 symptom classification methods to standardize the history component of the HEART score. Critical Pathways in Cardiology 16 (2017) 3:102-104.
- Robert F. Riley, MD, MS et al. Cost analysis of the History, ECG, Age, Risk factors, and initial Troponin (HEART) Pathway randomized control trial. American Journal of Emergency Medicine 35 (2017) 77–81