HEART outperformed both TIMI and GRACE in overall discriminative capacity for 30-day MACE. Using a single contemporary cTn at presentation, a HEART score of ≤3 demonstrated sensitivity and NPV of ≥99.5% for 30-day MACE. These results reach the threshold for a safe discharge strategy but should be interpreted thoughtfully in light of other work.
Objectives & BackgroundCardiac sounding chest pain is one of the commonest reasons for presentation to the Emergency Department (ED) or acute medical receiving. An electrocardiogram (ECG) can rapidly identify those patients suffering from an ST elevation acute coronary syndrome (ACS) but the differentiation of patients with non ST elevation ACS from those with non cardiac chest pain or stable cardiac disease is often not straightforward and encompasses historical, clinical and biochemical factors. Effective early risk stratification of this group of non ST elevated ACS patients may streamline care pathways for those at high risk and lead to effective use of resources and early discharge in those in whom ACS is unlikely.MethodsA prospective cohort study of adult patients presenting to the ED or acute medical receiving unit of Aberdeen Royal Infirmary with cardiac sounding chest pain and an a non-diagnostic ECG. A necessary sample size of 1000 patients was calculated and recruitment began in December 2014. HEART, GRACE and TIMI scores were calculated from data obtained on patient attendance, with subjective aspects entered by the attending medical practitioner in real time. Patients were followed up to 30 days for the development of a MACE. Receiver Operated Characteristic (ROC) curves were plotted to determine discriminative power of each of the three scores to detect MACE. Sensitivities and specificities (with 95% CIs) for each score (at different cut-offs) were calculated.ResultsPreliminary results are available on 605 patients. Ages ranged from 20–95 years (mean 61.8 years), 360 (59.5%) were male and 108 patients (17.9%) patients suffered a MACE at 30 days.Area under the ROC curves demonstrated that HEART (0.86) had a greater ability to discriminate patients going on to develop a MACE than TIMI (0.71) and GRACE (0.76) scores.Within the HEART low risk group 1.2% of patients developed a MACE and within the high risk group over 60% developed a MACE.ConclusionThe HEART score out performs GRACE and TIMI in predicting MACE in patients presenting to the ED with cardiac sounding chest pain. It rapidly identifies a low-risk population that may be suitable for early discharge or ambulatory management from the ED and higher risk patients may be promptly prioritised for invasive management.
Figure 1
Table 1Preliminary HEART Score DataRisk GroupHEART ScorePatients30 Day MACE (%)Low0–31672 (1.2)Intermediate4–632538 (11.7)High7–1011368 (60.2)
BackgroundTemporary lower limb immobilisation following injury is a risk factor for symptomatic venous thromboembolism (VTE). Pharmacological thromboprophylaxis can mitigate this risk but it is unclear which patients benefit from this intervention. The Aberdeen VTE risk tool was developed to tailor thromboprophylaxis decisions in these patients and this evaluation aimed to describe its performance in clinical practice. Secondarily, diagnostic metrics were compared with other risk assessment methods (RAMs).MethodsA prospective cohort service evaluation was conducted. Adult patients (≥16 years) managed with lower limb immobilisation for injury who were evaluated with the Aberdeen VTE risk tool prior to discharge from the ED were identified contemporaneously between February 2014 and December 2020. Electronic patient records were scrutinised up to 3 months after removal of immobilisation for the development of symptomatic VTE or sudden death due to pulmonary embolism (PE). Other RAMs, including the Thrombosis Risk Prediction for Patients with cast immobilisation (TRiP(cast)) and Plymouth scores, were assimilated retrospectively and diagnostic performance compared.ResultsOf 1763 patients (mean age 46 (SD 18) years, 51% women), 15 (0.85%, 95% CI 0.52% to 1.40%) suffered a symptomatic VTE or death due to PE. The Aberdeen VTE tool identified 1053 (59.7%) patients for thromboprophylaxis with a sensitivity of 80.0% (95% CI 54.8% to 93.0%) and specificity of 40.4% (95% CI 38.1% to 42.6%) for the primary outcome. In 1695 patients, fewer were identified as high risk by the TRiP(cast) (33.3%) and Plymouth (24.4%) scores, but with greater specificity, 67.0% and 75.6%, respectively, than dichotomous RAMs, including the Aberdeen VTE tool.ConclusionRoutine use of the Aberdeen VTE tool in our population resulted in an incidence of symptomatic VTE of less than 1%. Ordinal RAMs, such as the TRiP(cast) score, may more accurately reflect VTE risk and permit more individually tailored thromboprophylaxis decisions but prospective comparison is needed.
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