Evaluation of HEAR score to rule-out major adverse cardiac events without troponin test in patients presenting to the emergency department with chest pain

Abstract

Background and importanceCurrent guidelines for patients presenting to the emergency department with chest pain without ST-segment elevation myocardial infarction (non-STEMI) on electrocardiogram are based on troponin measurement. The HEART score is reportedly a reliable work-up strategy that combines clinical evaluation with troponin value. A clinical rule that could select very low-risk patients without the need for a blood test (HEAR score, being the HEART score without the troponin item) would be of great interest.Objectives To prospectively assess the safety of a HEAR score <2 to rule-out non-STEMI without troponin measurement. Secondary objective was to assess the safety of a sequential strategy that combines HEAR score and HEART (defined as two-step HEART strategy). Design, settings and participantsProspective observational study in six emergency departments. Patients with nontraumatic chest pain and no alternative diagnosis were included and followed up for 45 day. Patients were considered at low-risk if the HEAR score was <2 or, for the two-step HEART strategy, if the HEART score was <4. Outcomes measure and analysisThe primary endpoint was the 45-day rate of major adverse cardiac events (MACE) in patients with a HEAR score <2. A HEAR score based strategy was consider safe if the rate of the primary endpoint was below 1%, with an upper margin of the 95% confidence interval (CI) below 3%. ResultsAmong 1452 patients included, 1402 were analyzed and 97 (7%) had a MACE during the follow-up period. The HEAR score was <2 in 279 (20%) patients and one presented a MACE [0.4% (95% CI: 0.01-1.98)]. The two-step HEART strategy classified low-risk an additional 476 patients (34%) and one of these 476 patients had a MACE [0.3% (95% CI: 0.03-0.95)]. The two-step HEART strategy would have theoretically avoided 360 troponin measurements (19%). ConclusionsIn our prospective multicenter study, a HEAR based work-up strategy was safe, with a very low risk of MACE at 45 day. We also report that a twostep HEART-based strategy may safely allow significant reduction of troponin measurements in patients presenting to the emergency department with chest pain. European

The performance of HEAR score for identification of low-risk chest pain: a systematic review and meta-analysis

“…In this systematic review, 33 843 patients were included from 10 studies [9,10,33–40]. Five studies were conducted in Europe [9,33,34,38,40], one in Asia [37], and the rest in North America [10,35,36,39].…”

“…In this systematic review, 33 843 patients were included from 10 studies [9,10,33–40]. Five studies were conducted in Europe [9,33,34,38,40], one in Asia [37], and the rest in North America [10,35,36,39]. Seven studies were conducted in the EDs [9,10,34–38] and three studies were in the prehospital [33,39,40].…”

“…Seven studies were conducted in the EDs [9,10,[34][35][36][37][38] and three studies were in the prehospital [33,39,40]. Seven studies considered patients with the HEAR score below 2 [9,10,[33][34][35][36]38] and three studies marked scores below 4 as low risk [37,39,40]. Although no additional data were received through contacting the corresponding authors, we managed to extract data from the results of some studies using information in the text, figures, and tables.…”

“…In 4 of 10 studies, data on patients for the HEAR score at cutoff of 3 and 4 in the ED were extracted (Table 2) [9,34,35,37]. For HEAR score below 3, the pooled sensitivity, specificity, PPV, and NPV were 97.54% (95% CI, 94.50-100), 39.84% (95% CI, 35.65-44.02), 13.68% (95% CI, 6.53-20.83), and 99.75% (95% CI, 99.65-99.85), respectively.…”

Performances of HEART score to predict 6-month prognostic of emergency department patients with chest pain: a retrospective cohort analysis

“…From a recently published observational analysis of 151 patients emerged the concept that low-risk HEART score patients can be safely discharged with a reduced length of stay in ED and reduced health care costs [13]. Moreover, a modified score for pre-hospital patients (HEART score without Troponin) has been shown to have a high NPV for MACE at 45 days, reducing the need for troponin testing [14].…”