Chest Pain in the Emergency Room

Backus, Barbra E.; Six, A. Jacob; Kelder, Johannes C.; Mast, Thomas P.; Akker, F. van den; Mast, E. Gijis; Monnink, Shj; Tooren, Rob M. van; Doevendans, Pieter A.

doi:10.1097/hpc.0b013e3181ec36d8

Cited by 257 publications

(126 citation statements)

References 17 publications

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“…Hence, the HEART score was not developed using logistic regression modeling upon a real‐life database. Although male sex was reported to be a statistically significant predictor of MACE occurrence in previous HEART score validation studies, the HEART algorithm maintained similar discriminatory accuracy among men and women 14, 24, 25. In the prospective multicenter HEART score validation study, for example, Backus et al25 reported 6‐week MACE rates of 11.4% (116 of 1016) in women and 21.2% (291 of 1372) in men, with AUCs of 0.82 and 0.83, respectively.…”

Section: Discussionmentioning

confidence: 79%

“…Myocardial necrosis can often be confirmed or excluded within 1 to 3 hours,11, 12 but the interpretation of troponin levels depends on clinical context and repeated measurements. The HEART score13, 14 is a simple and effective clinical prediction rule incorporating both clinical context— H istory, E lectrocardiograph, A ge and R isk factors—and admission T roponin levels. Using solely information collected at time of presentation, the HEART score is able to accurately estimate a patient's short‐term cardiac risk, taking into account not only the risk of myocardial infarction during the index visit, but also major adverse cardiac events (MACE) that occur in the first 6 weeks thereafter.…”

Section: Introductionmentioning

confidence: 99%

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Sex‐Based Differences in the Performance of the HEART Score in Patients Presenting to the Emergency Department With Acute Chest Pain

Bank

Hoog

Kleijn

et al. 2017

JAHA

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BackgroundSex‐based differences in clinical presentation, pathophysiology, and outcomes of patients with acute chest pain are increasingly being recognized, but are not implemented in guidelines and clinical prediction tools. We evaluated the performance of the HEART score in women versus men, because sex‐based differences may exist among the algorithm's components: history, electrocardiogram, age, risk factors, and admission troponin level.Methods and ResultsThe HEART score was retrospectively assessed in 831 women and 1084 men presenting to the emergency department with acute chest pain, assigning patients to the low‐, intermediate‐, or high‐risk category for the occurrence of major adverse cardiac events (MACE) within 6 weeks. MACE, consisting of myocardial infarction, coronary revascularization, and all‐cause death, also included events during index visit. Six‐week MACE rates were 2 times lower in women than men (10.0% versus 20.8%; P<0.01). Despite similar discriminatory accuracy of the HEART score among women and men (c‐statistic, 0.80 [0.75–0.84] versus 0.77 [0.74–0.81]; P=0.43), 6‐week MACE rates were significantly lower in women than men across all HEART risk categories: 2.1% versus 6.5% (P<0.01) in the low‐risk category, 12.7% versus 21.3% (P<0.01) in intermediate‐risk category, and 53.1% versus 77.0% (P=0.02) in the high‐risk category. The HEART score‐adjusted risk ratio for men was 1.6 (1.3–2.0; P<0.01).ConclusionsThe markedly higher 6‐week MACE risk in men across all HEART risk categories should be taken into account when using the HEART score to guide clinical decision making; early discharge with a low‐risk HEART score appears less safe for men than women with acute chest pain.

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Section: Discussionmentioning

confidence: 79%

Section: Introductionmentioning

confidence: 99%

Sex‐Based Differences in the Performance of the HEART Score in Patients Presenting to the Emergency Department With Acute Chest Pain

Bank

Hoog

Kleijn

et al. 2017

JAHA

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“…ADPs required troponin measurement on arrival and then at 1, 2, or 3 hours to determine eligibility for early discharge. ADPs that were considered were the 2-Hour Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker (ADAPT) 10,14 ; Emergency Department Assessment of Chest Pain Score (EDACS) 15,17,18 ; History, ECG, Age, Risk Factors, and Troponin (HEART) 11,19 ; the High Sensitivity Cardiac Troponin T Assay for Rapid Rule-Out of AMI (TRAPID-AMI) 20,21 ; and the new Vancouver Chest Pain Rule. 13 Before implementation, there were meetings involving the first author and representatives from each stakeholder group (including but not limited to the ED, cardiology, general medicine physicians and nurses, hospital management, diagnostic laboratory directors, cardiac technicians, and hospital data analysts).…”

Section: Intervention Phasementioning

confidence: 99%

“…8,[10][11][12][13] Randomized implementation trials of clinical pathways incorporating ADPs at Christchurch Hospital (Christchurch, NZ) demonstrated that early safe discharge rates could be improved (from 11.0% to 32.3%). 14,15 Immediate and successful implementation of clinical pathways incorporating an ADP at Christchurch Hospital prompted the New Zealand Ministry of Health to mandate that all hospitals implement similar clinical pathways for possible ACS.…”

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confidence: 99%

ICare-ACS (Improving Care Processes for Patients With Suspected Acute Coronary Syndrome)

Than¹,

Pickering

Dryden³

et al. 2018

Circulation

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Background: Efforts to safely reduce length of stay for emergency department patients with symptoms suggestive of acute coronary syndrome (ACS) have had mixed success. Few system-wide efforts affecting multiple hospital emergency departments have ever been evaluated. We evaluated the effectiveness of a nationwide implementation of clinical pathways for potential ACS in disparate hospitals. Methods: This was a multicenter pragmatic stepped-wedge before-and-after trial in 7 New Zealand acute care hospitals with 31 332 patients investigated for suspected ACS with serial troponin measurements. The implementation was a clinical pathway for the assessment of patients with suspected ACS that included a clinical pathway document in paper or electronic format, structured risk stratification, specified time points for electrocardiographic and serial troponin testing within 3 hours of arrival, and directions for combining risk stratification and electrocardiographic and troponin testing in an accelerated diagnostic protocol. Implementation was monitored for >4 months and compared with usual care over the preceding 6 months. The main outcome measure was the odds of discharge within 6 hours of presentation Results: There were 11 529 participants in the preimplementation phase (range, 284–3465) and 19 803 in the postimplementation phase (range, 395–5039). Overall, the mean 6-hour discharge rate increased from 8.3% (range, 2.7%–37.7%) to 18.4% (6.8%–43.8%). The odds of being discharged within 6 hours increased after clinical pathway implementation. The odds ratio was 2.4 (95% confidence interval, 2.3–2.6). In patients without ACS, the median length of hospital stays decreased by 2.9 hours (95% confidence interval, 2.4–3.4). For patients discharged within 6 hours, there was no change in 30-day major adverse cardiac event rates (0.52% versus 0.44%; P =0.96). In these patients, no adverse event occurred when clinical pathways were correctly followed. Conclusions: Implementation of clinical pathways for suspected ACS reduced the length of stay and increased the proportions of patients safely discharged within 6 hours. Clinical Trial Registration: URL: https://www.anzctr.org.au/ (Australian and New Zealand Clinical Trials Registry). Unique identifier: ACTRN12617000381381.

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“…The HEART score (History, ECG, Age, Risk Factors, Troponin), for example, uses elements of the patient's history, ECG findings, age, risk factors for coronary artery disease and initial coronary artery disease to identify a group of patients that could be immediately discharged. 12 AMI could potentially also be 'ruled out' in patients with hs-cTnT concentrations below the limit of detection of the assay and no ECG ischaemia. [13][14][15][16] Other tools, such as the Emergency Department Assessment of Chest Pain Score (ED-ACS) or bespoke algorithms to rule out AMI with hs-cTnT testing alone, could be used to discharge more patients following serial troponin testing after 1 to 2 hours.…”

Section: Future Directionsmentioning

confidence: 99%

Feasibility of the Manchester Acute Coronary Syndromes (MACS) decision rule to safely reduce unnecessary hospital admissions: a pilot randomised controlled trial

et al. 2017

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BackgroundObservational studies suggest that the Manchester Acute Coronary Syndromes (MACS) decision rule can effectively ‘rule out’ and ‘rule in’ acute coronary syndromes (ACS) following a single blood test. In a pilot randomised controlled trial, we aimed to determine whether a large trial is feasible.MethodsPatients presenting to two EDs with suspected cardiac chest pain were randomised to receive care guided by the MACS decision rule (intervention group) or standard care (controls). The primary efficacy outcome was a successful discharge from the ED, defined as a decision to discharge within 4 hours of arrival providing that the patient did not have a missed acute myocardial infarction (AMI) or develop a major adverse cardiac event (MACE: death, AMI or coronary revascularisation) within 30 days. Feasibility outcomes included recruitment and attrition rates.ResultsIn total, 138 patients were included between October 2013 and October 2014, of whom 131 (95%) were randomised (66 to intervention and 65 controls). Nine (7%) patients had prevalent AMI and six (5%) had incident MACE within 30 days. All 131 patients completed 30-day follow-up and were included in the final analysis with no missing data for the primary analyses. Compared with standard care, a significantly greater proportion of patients whose care was guided by the MACS rule were successfully discharged within 4 hours (26% vs 8%, adjusted OR 5.45, 95% CI 1.73 to 17.11, p=0.004). No patients in either group who were discharged within 4 hours had a diagnosis of AMI or incident MACE within 30 days (0.0%, 95% CI 0% to 20.0% in the intervention group).ConclusionsIn this pilot trial, use of the MACS rule led to a significant increase in safe discharges from the ED but a larger, fully powered trial remains necessary. Our findings seem to support the feasibility of that trial.Trial registration numberISRCTN 86818215.Research Ethics Committee reference13/NW/0081.UKCRN registration ID14334.

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Chest Pain in the Emergency Room

Abstract: The HEART score helps in making accurate diagnostic and therapeutic decisions without the use of radiation or invasive procedures. The HEART score is an easy, quick, and reliable predictor of outcome in chest pain patients and can be used for triage.

Cited by 257 publications

References 17 publications

Sex‐Based Differences in the Performance of the HEART Score in Patients Presenting to the Emergency Department With Acute Chest Pain

Sex‐Based Differences in the Performance of the HEART Score in Patients Presenting to the Emergency Department With Acute Chest Pain

ICare-ACS (Improving Care Processes for Patients With Suspected Acute Coronary Syndrome)

Feasibility of the Manchester Acute Coronary Syndromes (MACS) decision rule to safely reduce unnecessary hospital admissions: a pilot randomised controlled trial

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