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Aarts GWA, Camaro C, Adang EMM, Rodwell L, van Hout R, Brok G, Hoare A, de Pooter F, de Wit W, Cramer GE, van Kimmenade RRJ, Ouwendijk E, Rutten MH, Zegers E, van Geuns RJM, Gomes MER, Damman P, van Royen N. Pre-hospital rule-out of non-ST-segment elevation acute coronary syndrome by a single troponin: final one-year outcomes of the ARTICA randomised trial. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:411-420. [PMID: 38236708 PMCID: PMC11307197 DOI: 10.1093/ehjqcco/qcae004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/02/2024] [Accepted: 01/15/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND AND AIMS The healthcare burden of acute chest pain is enormous. In the randomized ARTICA trial, we showed that pre-hospital identification of low-risk patients and rule-out of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) with point-of-care (POC) troponin measurement reduces 30-day healthcare costs with low major adverse cardiac events (MACE) incidence. Here we present the final 1-year results of the ARTICA trial. METHODS Low-risk patients with suspected NSTE-ACS were randomized to pre-hospital rule-out with POC troponin measurement or emergency department (ED) transfer. Primary 1-year outcome was healthcare costs. Secondary outcomes were safety, quality of life (QoL), and cost-effectiveness. Safety was defined as a 1-year MACE consisting of ACS, unplanned revascularization, or all-cause death. QoL was measured with EuroQol-5D-5L questionnaires. Cost-effectiveness was defined as 1-year healthcare costs difference per QoL difference. RESULTS Follow-up was completed for all 863 patients. Healthcare costs were significantly lower in the pre-hospital strategy (€1932 ± €2784 vs. €2649 ± €2750), mean difference €717 [95% confidence interval (CI) €347 to €1087; P < 0.001]. In the total population, the 1-year MACE rate was comparable between groups [5.1% (22/434) in the pre-hospital strategy vs. 4.2% (18/429) in the ED strategy; P = 0.54]. In the ruled-out ACS population, 1-year MACE remained low [1.7% (7/419) vs. 1.4% (6/417)], risk difference 0.2% (95% CI -1.4% to 1.9%; P = 0.79). QoL showed no significant difference between strategies. CONCLUSIONS Pre-hospital rule-out of NSTE-ACS with POC troponin testing in low-risk patients is cost-effective, as expressed by a sustainable healthcare cost reduction and no significant effect on QoL. One-year MACE remained low for both strategies.
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Affiliation(s)
- Goaris W A Aarts
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Cyril Camaro
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Eddy M M Adang
- Department of Health Evidence, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Laura Rodwell
- Department of Health Evidence, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Roger van Hout
- Ambulance Service, Safety Region Gelderland-Zuid, Nijmegen, The Netherlands
| | - Gijs Brok
- Ambulance Service, Safety Region Gelderland-Zuid, Nijmegen, The Netherlands
| | - Anouk Hoare
- Ambulance Service, Witte Kruis, Houten, The Netherlands
| | - Frank de Pooter
- Ambulance Service, Witte Kruis, Safety Region Noord-en Oost-Gelderland, Elburg, The Netherlands
| | - Walter de Wit
- Ambulance Service, Witte Kruis, Safety Region Zeeland, Goes, The Netherlands
| | - Gilbert E Cramer
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Eva Ouwendijk
- General Practitioner Centre Nijmegen and Boxmeer, Nijmegen, The Netherlands
| | - Martijn H Rutten
- General Practitioner Cooperative Noord-Limburg, Venlo, The Netherlands
| | - Erwin Zegers
- Department of Cardiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | | | - Marc E R Gomes
- Department of Cardiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Ola O, Akula A, De Michieli L, Knott JD, Lobo R, Mehta RA, Hodge DO, Gulati R, Sandoval Y, Jaffe AS. Use of the HEAR Score for 30-Day Risk-Stratification in Emergency Department Patients. Am J Med 2023; 136:918-926.e5. [PMID: 37236417 DOI: 10.1016/j.amjmed.2023.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 04/27/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND The 2021 American College of Cardiology/American Heart Association chest pain guidelines recommend risk scores such as HEAR (History, Electrocardiogram, Age, Risk factors) for short-term risk stratification, yet limited data exist integrating them with high-sensitivity cardiac troponin T (hs-cTnT). METHODS Retrospective, multicenter (n = 2), observational, US cohort study of consecutive emergency department patients without ST-elevation myocardial infarction who had at least one hs-cTnT (limit of quantitation [LoQ] <6 ng/L, and sex-specific 99th percentiles of 10 ng/L for women and 15 ng/L for men) measurement on clinical indications in whom HEAR scores (0-8) were calculated. The composite major adverse cardiovascular event (MACE) outcome was 30-day prognosis. RESULTS Among 1979 emergency department patients undergoing hs-cTnT measurement, 1045 (53%) were low risk (0-3), 914 (46%) intermediate risk (4-6), and 20 (1%) high risk (7-8) based on HEAR scores. HEAR scores were not associated with increased risk of 30-day MACE in adjusted analyses. Patients with quantifiable hs-cTnT (LoQ-99th) had an increased risk for 30-day MACE (3.4%) irrespective of HEAR scores. Those with serial hs-cTnT <99th percentile remained at low risk (range 0%-1.2%) across all HEAR score strata. Higher scores were not associated with long-term (2-year) events. CONCLUSIONS HEAR scores are of limited value in those with baseline hs-cTnT 99th percentile to define short-term prognosis. In those with baseline quantifiable hs-cTnT within the reference range (<99th percentile), a higher risk (>1%) for 30-day MACE exists even in those with low HEAR scores. With serial hs-cTnT measurements, HEAR scores overestimate risk when hs-cTnT remains <99th percentile.
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Affiliation(s)
- Olatunde Ola
- Division of Hospital Internal Medicine, Mayo Clinic Health System, La Crosse, Wis; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minn
| | - Ashok Akula
- Division of Hospital Internal Medicine, Mayo Clinic Health System, La Crosse, Wis; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, Minn
| | - Laura De Michieli
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn; Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Italy
| | | | - Ronstan Lobo
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
| | - Ramila A Mehta
- Department of Quantitative Health Sciences, Mayo College of Medicine, Rochester, Minn
| | - David O Hodge
- Department of Quantitative Health Sciences, Mayo College of Medicine, Jacksonville, Fla
| | - Rajiv Gulati
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
| | - Yader Sandoval
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn; Minneapolis Heart Institute, Abbott Northwestern Hospital and Minneapolis Heart Institute Foundation, Minn
| | - Allan S Jaffe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minn.
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Moustapha A, Mah AC, Roberts L, Leach A, Kaban G, Zimmermann R, Shavadia J, Orvold J, Mondal P, Martin LJ. Can ED chest pain patients with intermediate HEART scores be managed as outpatients? CAN J EMERG MED 2022; 24:770-779. [PMID: 36129627 DOI: 10.1007/s43678-022-00355-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 06/28/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Current guidelines recommend hospital admission for patients who present to the emergency department (ED) with chest pain and are scored as intermediate risk for adverse outcomes based on the HEART score. While hospital admission for these patients allows for timely investigation and treatment, it is a resource-intensive process. This study examines whether intermediate HEART score patients can be safely managed on an outpatient basis through rapid access chest pain clinics. METHODS This retrospective observational study included all ED chest pain patients referred to rapid access clinics from January 2018 to April 2020 in Regina and Saskatoon, Saskatchewan. ED physician HEART scores were used in lieu of reviewer HEART scores when available. The primary outcome was the rate of major adverse coronary events (MACE), a composite measure of death, acute coronary syndrome, stroke, coronary angiography, and revascularization at 6 weeks in intermediate-risk patients. Secondary outcomes were the type of MACE, rate of MACE before rapid access clinic appointment and the most predictive component of the HEART score. RESULTS There were 1989 ED referrals, of which 817 were for intermediate-risk patients. 9.3% of intermediate-risk patients had a MACE at 6 weeks. MACE occurred before rapid access clinic follow-up in 1.1% of intermediate-risk patients, with coronary angiography being the most common MACE. Excluding coronary angiography, the risk of MACE before rapid access clinic follow-up was 0.7% in intermediate-risk patients. Components of the HEART score most predictive of MACE were troponin (OR 11.0, 95% CI: 3.7-32.3) and history (5.3, 95% CI: 2.4-11.8). CONCLUSION This study demonstrates that rapid access clinics are likely a safe alternative to admission for intermediate-risk chest pain patients and could reduce costly inpatient admissions for chest pain. With angiography excluded, MACE rates were well below the American College of Emergency Physicians cited 2% threshold.
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Affiliation(s)
- Aisha Moustapha
- College of Medicine, University of Saskatchewan, Regina, SK, Canada
| | - Alicia C Mah
- College of Medicine, University of Saskatchewan, Regina, SK, Canada
| | - Lauren Roberts
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Andrew Leach
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Glenda Kaban
- Department of Emergency Medicine, University of Saskatchewan, Regina, SK, Canada
| | - Rodney Zimmermann
- Department of Internal Medicine - Division of Cardiology, University of Saskatchewan, Regina, SK, Canada
| | - Jay Shavadia
- Department of Internal Medicine - Division of Cardiology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Jason Orvold
- Department of Internal Medicine - Division of Cardiology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Prosanta Mondal
- Clinical Research Support Unit, College of Medicine, Saskatoon, SK, Canada
| | - Lynsey J Martin
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada.
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Yang B, Bai L, Zhang Y, Cheng Y, Zhao C, Huang B, Chen M. The Value of Different Short-Term Risk Scoring Models in Predicting Long-Term Death of Acute Myocardial Infarction. J Clin Med 2022; 11:jcm11175054. [PMID: 36078986 PMCID: PMC9457293 DOI: 10.3390/jcm11175054] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 08/23/2022] [Accepted: 08/25/2022] [Indexed: 11/30/2022] Open
Abstract
Background and aims: To compare the value of three commonly used cardiovascular short-term risk scoring models, the GRACE score, TIMI score, and HEART score, in predicting the long-term prognosis of patients with acute myocardial infarction. Methods: The hospitalization data of patients who were hospitalized in West China Hospital of Sichuan University from 2011 to 2013 and diagnosed with acute myocardial infarction (AMI) were collected. The patients were scored by GRACE score, TIMI score, and HEART score. The long-term follow-up of patients was conducted until the end of January 2021. All-cause death and time of death of patients were confirmed by telephone follow-up, electronic medical record query, and household registration information. The predictive ability of different risk scores for long-term prognosis was compared according to the receiver operating characteristic (ROC) area under the curve (AUC), and the ability to distinguish patients with different risk levels was compared according to Kaplan−Meier survival curves. Results: The study ultimately included 2220 patients, with a median follow-up of 8 years and 454 (20.5%) deaths until the end of follow-up. Whether in ST-segment elevation myocardial infarction (STEMI) patients or non-ST-segment elevation myocardial infarction (NSTEMI) patients, the AUC value of the GRACE score (both AUC = 0.734) was significantly higher than the TIMI score (AUC = 0.675, p < 0.01; AUC = 0.665, p < 0.01) and HEART score (AUC = 0.632, p < 0.01; AUC = 0.611, p < 0.01) until the end of follow-up. In terms of risk stratification, the Kaplan−Meier survival curve shows that both THE GRACE score and TIMI score can distinguish AMI patients with different risk levels (p < 0.01), but the risk stratification ability of the HEART score in AMI patients was poor (p > 0.05). Conclusion: The GRACE risk score could represent a more accurate model to assess long-term death of acute myocardial infarction, but further studies are required.
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Liu N, Chee ML, Koh ZX, Leow SL, Ho AFW, Guo D, Ong MEH. Utilizing machine learning dimensionality reduction for risk stratification of chest pain patients in the emergency department. BMC Med Res Methodol 2021; 21:74. [PMID: 33865317 PMCID: PMC8052947 DOI: 10.1186/s12874-021-01265-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 04/05/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Chest pain is among the most common presenting complaints in the emergency department (ED). Swift and accurate risk stratification of chest pain patients in the ED may improve patient outcomes and reduce unnecessary costs. Traditional logistic regression with stepwise variable selection has been used to build risk prediction models for ED chest pain patients. In this study, we aimed to investigate if machine learning dimensionality reduction methods can improve performance in deriving risk stratification models. METHODS A retrospective analysis was conducted on the data of patients > 20 years old who presented to the ED of Singapore General Hospital with chest pain between September 2010 and July 2015. Variables used included demographics, medical history, laboratory findings, heart rate variability (HRV), and heart rate n-variability (HRnV) parameters calculated from five to six-minute electrocardiograms (ECGs). The primary outcome was 30-day major adverse cardiac events (MACE), which included death, acute myocardial infarction, and revascularization within 30 days of ED presentation. We used eight machine learning dimensionality reduction methods and logistic regression to create different prediction models. We further excluded cardiac troponin from candidate variables and derived a separate set of models to evaluate the performance of models without using laboratory tests. Receiver operating characteristic (ROC) and calibration analysis was used to compare model performance. RESULTS Seven hundred ninety-five patients were included in the analysis, of which 247 (31%) met the primary outcome of 30-day MACE. Patients with MACE were older and more likely to be male. All eight dimensionality reduction methods achieved comparable performance with the traditional stepwise variable selection; The multidimensional scaling algorithm performed the best with an area under the curve of 0.901. All prediction models generated in this study outperformed several existing clinical scores in ROC analysis. CONCLUSIONS Dimensionality reduction models showed marginal value in improving the prediction of 30-day MACE for ED chest pain patients. Moreover, they are black box models, making them difficult to explain and interpret in clinical practice.
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Affiliation(s)
- Nan Liu
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore.
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore.
- Institute of Data Science, National University of Singapore, Singapore, Singapore.
| | - Marcel Lucas Chee
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Zhi Xiong Koh
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Su Li Leow
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Andrew Fu Wah Ho
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Dagang Guo
- SingHealth Duke-NUS Emergency Medicine Academic Clinical Programme, Singapore, Singapore
| | - Marcus Eng Hock Ong
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- Health Services Research Centre, Singapore Health Services, Singapore, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
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Oliver JJ, Streitz MJ, Hyams JM, Wood RM, Maksimenko YM, Schauer SG, Long B, Barnwell RM, Bridwell RE, April MD. The HEART score as a prognostic tool for revascularization. Intern Emerg Med 2020; 15:607-612. [PMID: 31625076 DOI: 10.1007/s11739-019-02206-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 09/27/2019] [Indexed: 11/29/2022]
Abstract
The History, Electrocardiogram, Age, Risk Factors, Troponin (HEART) score is a useful tool in the Emergency Department setting to identify those patients safe for outpatient evaluation of chest pain. Its utility for predicting cardiac interventions is unclear. Our objective was to evaluate the prognostic accuracy of the HEART score to predict the need for cardiac stent or coronary artery bypass grafting (CABG). We conducted a retrospective chart review of 625 consecutive subjects with chest pain presenting to an Emergency Department (ED) with a HEART pathway protocol in place. We also reviewed each subject's record for evidence of major adverse cardiac events within 6 weeks following their ED visit. We double-abstracted 10% of the charts for quality assurance. We included subjects if they were ≥ 18 at the time of presentation and had a chief complaint of chest pain. We excluded subjects if they did not have an electrocardiogram or troponin, or if their chart lacked sufficient information to calculate the history portion of their HEART score. Of 625 charts, 449 subjects met criteria for study inclusion. The area under the receiver operator curve reported as c-statistics was 0.877 [95% confidence interval (CI) 0.806-0.949] for the HEART score's ability to predict cardiac stent and 0.921 (95% CI 0.858-0.984) for CABG. There is a strong association between increasing HEART scores and the need for revascularization which may provide emergency physicians justification for expedited cardiology consultation and admission for these patients. These findings require further prospective validation.
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Affiliation(s)
- Joshua James Oliver
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA.
| | - Matthew Jay Streitz
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | - Jessica Marie Hyams
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | - Richard Michael Wood
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | | | - Steven Gremel Schauer
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | - Brit Long
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | - Robert Michael Barnwell
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | - Rachel Elisabeth Bridwell
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
| | - Michael David April
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA
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HEART Score Risk Stratification of Low-Risk Chest Pain Patients in the Emergency Department: A Systematic Review and Meta-Analysis. Ann Emerg Med 2019; 74:187-203. [DOI: 10.1016/j.annemergmed.2018.12.010] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 11/12/2018] [Accepted: 12/05/2018] [Indexed: 01/26/2023]
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Incorporation of the HEART Score Into a Low-risk Chest Pain Pathway to Safely Decrease Admissions. Crit Pathw Cardiol 2019; 17:184-190. [PMID: 30418248 DOI: 10.1097/hpc.0000000000000155] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Chest pain can be a challenging complaint to manage in the emergency department. A missed diagnosis can result in significant morbidity or mortality, whereas avoidable testing and hospitalizations can lead to increased health care costs, contribute to hospital crowding, and increase risks to patients. The HEART score is a validated decision aid to identify patients at low risk for acute coronary syndrome who can be safely discharged without admission or objective cardiac testing. In the largest and one of the longest studies to date (N = 31,060; 30 months), we included the HEART score into a larger, newly developed low-risk chest pain decision pathway, using a retrospective observational pre/post study design with the objective of safely lowering admissions. The modified HEART score calculation tool was incorporated in our electronic medical record. A significant increase in discharges of low-risk chest pain patients (relative increase of 21%; p < 0.0001) in the postimplementation period was observed with no significant difference in the rates of major adverse cardiac events between the pre and post periods. There was a decrease in the amount of return admissions for 30 days (4.65% fewer; p = 0.009) and 60 days (3.78% fewer; p = 0.020). No significant difference in length of stay was observed for patients who were ultimately discharged. A 64% decrease in monthly coronary computed tomography angiograms was observed in the post period (p < 0.0001). These findings support the growing consensus in the literature that the adoption of the HEART pathway or similar protocols in emergency departments, including at large and high-volume medical institutions, can substantially benefit patient care and reduce associated health care costs.
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Fernando SM, Tran A, Cheng W, Rochwerg B, Taljaard M, Thiruganasambandamoorthy V, Kyeremanteng K, Perry JJ. Prognostic Accuracy of the HEART Score for Prediction of Major Adverse Cardiac Events in Patients Presenting With Chest Pain: A Systematic Review and Meta-analysis. Acad Emerg Med 2019; 26:140-151. [PMID: 30375097 DOI: 10.1111/acem.13649] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/04/2018] [Accepted: 08/13/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The HEART score has been proposed for emergency department (ED) prediction of major adverse cardiac events (MACE). We sought to summarize all studies assessing the prognostic accuracy of the HEART score for prediction of MACE in adult ED patients presenting with chest pain. METHODS We searched MEDLINE, PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews from inception through May 2018 and included studies using the HEART score for the prediction of short-term MACE in adult patients presenting to the ED with chest pain. The main outcome was short-term (i.e., 30-day or 6-week) incidence of MACE. We secondarily evaluated the prognostic accuracy of the HEART score for prediction of mortality and myocardial infarction (MI). Where available, accuracy of the Thrombolysis in Myocardial Infarction (TIMI) score was determined. RESULTS We included 30 studies (n = 44,202) in analysis. A HEART score above the low-risk threshold (≥4) had a sensitivity of 95.9% (95% confidence interval [CI] = 93.3%-97.5%) and specificity of 44.6% (95% CI = 38.8%-50.5%) for MACE. A high-risk HEART score (≥7) had a sensitivity of 39.5% (95% CI = 31.6%-48.1%) and specificity of 95.0% (95% CI = 92.6%-96.6%) for MACE, whereas a TIMI score above the low-risk threshold (≥2) had a sensitivity of 87.8% (95% CI = 80.2%-92.8%) and specificity of 48.1% (95% CI = 38.9%-57.5%) for MACE. A high-risk TIMI score (≥6) was 2.8% sensitive (95% CI = 0.8%-9.6%), but 99.6% (95% CI = 98.5%-99.9%) specific for MACE. A HEART score ≥ 4 had a sensitivity of 95.0% (95% CI = 87.2%-98.2%) for prediction of mortality and 97.5% (95% CI = 93.7%-99.0%) for prediction of MI. CONCLUSIONS The HEART score has excellent performance for prediction of MACE (particularly mortality and MI) in chest pain patients and should be the primary clinical decision instrument used for the risk stratification of this patient population.
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Affiliation(s)
- Shannon M. Fernando
- Department of Emergency Medicine; University of Ottawa; Ottawa Ontario
- Division of Critical Care; Department of Medicine; University of Ottawa; Ottawa Ontario
| | - Alexandre Tran
- School of Epidemiology and Public Health; University of Ottawa; Ottawa Ontario
- Department of Surgery; University of Ottawa; Ottawa Ontario
| | - Wei Cheng
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; Ottawa Ontario
| | - Bram Rochwerg
- Department of Medicine; Division of Critical Care, and Department of Health Research Methods, Evidence, and Impact; McMaster University; Hamilton Ontario Canada
| | - Monica Taljaard
- School of Epidemiology and Public Health; University of Ottawa; Ottawa Ontario
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; Ottawa Ontario
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine; University of Ottawa; Ottawa Ontario
- School of Epidemiology and Public Health; University of Ottawa; Ottawa Ontario
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; Ottawa Ontario
| | - Kwadwo Kyeremanteng
- Division of Critical Care; Department of Medicine; University of Ottawa; Ottawa Ontario
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; Ottawa Ontario
| | - Jeffrey J. Perry
- Department of Emergency Medicine; University of Ottawa; Ottawa Ontario
- School of Epidemiology and Public Health; University of Ottawa; Ottawa Ontario
- Clinical Epidemiology Program; Ottawa Hospital Research Institute; Ottawa Ontario
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Michaels A, Gibbs J, Mawri S, Dirani G, Aurora L, Jacobsen G, Nowak R, McCord J. Prognostic Utility of the HEART Score in the Observation Unit. Crit Pathw Cardiol 2018; 17:179-183. [PMID: 30418247 DOI: 10.1097/hpc.0000000000000157] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The evaluation of individuals with possible acute myocardial infarction (AMI) is time consuming and costly. Risk stratification early during an acute care encounter presents an opportunity for increased delivery of high-value care. We sought to evaluate if the HEART score could be used in the triage of low-risk versus high-risk patients directly home without cardiac testing. Retrospective review of 838 patients placed in an observation unit for evaluation of AMI was done at a single-center, tertiary care teaching hospital. Primary outcome was major adverse cardiac event-death, AMI, or revascularization-at 30 days from the index encounter. Participants' average age was 60.1 years, 40% were male, and 67% were African American. Complete data were available for all 838 patients, including 30-day follow-up at study completion. The primary endpoint was met in 14 patients (1.7%), all of whom were in the high-risk group, with HEART score ≥4. Of the low-risk patients, 8 (2.8%) had a positive functional study, 5 underwent subsequent coronary angiography, with none (0%) found to have obstructive coronary disease. In conclusion, our results suggest that patients with a HEART score ≤3 being evaluated for chest pain are at extremely low risk for major adverse cardiac events and may be safely discharged without provocative testing. Positive cardiac testing in this population is more likely to represent a false-positive finding, resulting in unnecessary testing. These findings should be prospectively validated.
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Affiliation(s)
- Alexander Michaels
- From the Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Joseph Gibbs
- From the Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - Sagger Mawri
- From the Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
| | - George Dirani
- Department Cardiovascular Medicine, Beaumont-Dearborn, Dearborn, MI
| | - Lindsey Aurora
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI
| | - Gordon Jacobsen
- Public Health Sciences, Public Health and Statistics, Henry Ford Hospital, Detroit, MI
| | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI
| | - James McCord
- From the Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI
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Tesson A, Abdo R, Kamath A, Sutter J, Cline R, Hale SL, Bae J, Verma L. HEART Failure? Episodes of Missed Major Cardiac Events When Applying the HEART Pathway to an Observation Unit Population. Crit Pathw Cardiol 2018; 17:88-94. [PMID: 29768317 DOI: 10.1097/hpc.0000000000000137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The HEART Pathway risk prediction tool (HEART score plus serial troponin measures at 0 and 3 hours post-presentation) is used to identify low-risk patients with chest pain who may qualify for safe, early discharge. We calculated the percentage of patients in our observation unit that qualified as low risk using HEART Pathway, as well as their associated outcomes. METHODS We retrospectively reviewed charts on 966 consecutive patients admitted to our observation unit for chest pain (January 2015 to February 2016); HEART Pathway scores were retrospectively calculated and serial cardiac troponin values logged. The primary outcome was 42-day major adverse cardiac events (MACE), including acute myocardial infarction, urgent revascularization, and all-cause death. RESULTS The patients' mean age was 59, 42% were male, 46% white, and 68 (7.7%) had MACE. HEART Pathway defined 384 patients as low risk (39.8%) and eligible for early discharge. Applying HEART Pathway would have missed 1.2% of patients with MACE; however, all adverse cardiac events occurred in patients with a HEART Pathway score of 3 (4 of 193, 2.1%) and none in those with a HEART Pathway score ≤2 (0 of 134). CONCLUSIONS While the HEART Pathway identifies a pooled population at low risk for MACE, risk is not homogenous within this population. Patients with a score of 3 may have higher risk of 42-day MACE that may be unacceptable to some providers, while scores ≤2 saw no events. Caution is advised for those with HEART Pathway score of 3 until more data is available to accurately estimate risk.
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Affiliation(s)
- Alan Tesson
- From the Department of Hospital Medicine, Duke University Health Systems, Durham, NC
| | - Rami Abdo
- From the Department of Hospital Medicine, Duke University Health Systems, Durham, NC
| | - Aparna Kamath
- From the Department of Hospital Medicine, Duke University Health Systems, Durham, NC
| | - Joanne Sutter
- From the Department of Hospital Medicine, Duke University Health Systems, Durham, NC
| | - Rachel Cline
- From the Department of Hospital Medicine, Duke University Health Systems, Durham, NC
| | - Sarah L Hale
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC
| | - Jonathan Bae
- From the Department of Hospital Medicine, Duke University Health Systems, Durham, NC
| | - Lalit Verma
- From the Department of Hospital Medicine, Duke University Health Systems, Durham, NC
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Clinical utility of the HEART score in patients admitted with chest pain to an inner-city hospital in the USA. Coron Artery Dis 2018; 28:336-341. [PMID: 28288007 DOI: 10.1097/mca.0000000000000474] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Chest pain is one of the most common presentations to a hospital, and appropriate triaging of these patients can be challenging. The HEART score has been used for such purposes in some countries and only a few validation studies from the USA are available. We aim to determine the utility of the HEART score in patients presenting with chest pain to an inner-city hospital in the USA. PATIENTS AND METHODS We retrospectively screened 417 consecutive patients admitted with chest pain to the observation/telemetry units at Einstein Medical Center Philadelphia. After applying inclusion and exclusion criteria, 299 patients were included in the analysis. Patients were divided into low-risk (0-3) and intermediate-high (≥4)-risk HEART score groups. Baseline characteristics, thrombolysis in myocardial infarction score, need for revascularization during index hospitalization, and major adverse cardiovascular events (MACE) at 6 weeks and 12 months were recorded. RESULTS There were 98 and 201 patients in the low-score group and intermediate-high-score group, respectively. Compared with the low-score group, patients in the intermediate-high-risk group had a higher incidence of revascularization during the index hospital stay (16.4 vs. 0%; P=0.001), longer hospital stay, higher MACE at 6 weeks (9.5 vs. 0%) and 12 months (20.4 vs. 3.1%), and higher cardiac readmissions. HEART score of at least 4 independently predicted MACE at 12 months (odds ratio 7.456, 95% confidence interval: 2.175-25.56; P=0.001) after adjusting for other risk factors in regression analysis. CONCLUSION HEART score of at least 4 was predictive of worse outcomes in patients with chest pain in an inner-city USA hospital. If validated in multicenter prospective studies, the HEART score could potentially be useful in risk-stratifying patients presenting with chest pain in the USA and could impact clinical decision-making.
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Davis A, Chiu J, Lau SK, Kok YJ, Wu JYH. Efficacy of Implementation of a Chest Pain Center at a Community Hospital. Crit Pathw Cardiol 2017; 16:135-141. [PMID: 29135621 DOI: 10.1097/hpc.0000000000000133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Chest pain is the second leading cause for emergency department (ED) visits in the United States; however, <20% of the patients have acute coronary syndrome that require immediate attention. The HEART score is designed for rapid risk stratification of ED chest pain patients using the following criteria: history, electrocardiogram, age, risk factors, and troponin. It has been shown to be superior in identifying patients with low (HEART score 0-3) and high (7-10) risk of major adverse cardiac events, who can then be rapidly discharged or admitted for intervention. OBJECTIVE This retrospective review and assessment sought to evaluate the efficacy of implementation of a Chest Pain Center (CPC) at a predominantly Asian-based community hospital in the United States. Additionally, this assessment sought to evaluate the effectiveness and safety of a HEART protocol in the first 4 months after its adoption. MATERIALS AND METHODS The facility implemented the CPC, an observation unit, in October 2016. ED physicians risk stratified patients using the HEART score. The guidelines allow ED physicians to stratify patients into 3 categories: to discharge low-risk patients, observe moderate-risk patients in the CPC, and admit high-risk patients. Patients in the CPC received additional diagnostic work-up under the care of ED physicians and cardiologists for less than 24 hours. In addition, CPC patients were followed-up 2 and 30 days after discharge. RESULTS A total of 172 patients presented at the ED with a chief complaint of chest pain. The majority of the patients were classified into the moderate-risk group (n = 101). Low-risk patients spent significantly less hours in the hospital than the moderate- and high-risk groups, and the high-risk group spent more time in the hospital than the moderate-risk group. The staff followed-up with 74 CPC patients through telephone calls to assess if patients were still experiencing chest pain and if they had followed-up with a cardiologist or primary care physician. The 2- and 30-day survival rates were 100% and 97%, respectively. DISCUSSION The data showed a significant reduction in total length of stay for all chest pain patients. This retrospective program evaluation demonstrated some evidence in using HEART score to safely risk stratify chest pain patients to the appropriate level of care. As healthcare moves from a fee-for-service environment to value-based purchasing, hospitals need to devise and implement innovative strategies to provide efficient, beneficial, and safe care for the patients.
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Affiliation(s)
- Alexandra Davis
- From the *Department of Emergency Medicine, Southern California Heart Centers, San Gabriel, CA; and †Garfield Medical Center, Monterey Park, CA
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