HEART Failure? Episodes of Missed Major Cardiac Events When Applying the HEART Pathway to an Observation Unit Population

Tesson, Alan; Abdo, Rami; Kamath, Aparna; Sutter, Joanne; Cline, Rachel; Hale, Sarah; Bae, Jonathan; Verma, Lalit

doi:10.1097/hpc.0000000000000137

Cited by 4 publications

(3 citation statements)

References 25 publications

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“…This has not yet been the subject of meta-analysis; however, we describe the reports from our search that detail sensitivity in Table 5. 10,12,13,18,32,50,[57][58][59][60][61] Most are underpowered, and the 2 with the strongest lower confidence interval bounds report these values as 96%, ie, compatible with missing 4% of major adverse cardiac events and outside of the 1% to 2% desirable threshold discussed previously. We note limitations to these 2 studies as follows.…”

Section: Is the Rule's Performance Sufficiently Precise? (Noncompliant)mentioning

confidence: 92%

“…The distinction between negative predictive value and sensitivity is easy to miss when reviewing the medical literature, as some authors use ambiguous terminology such as "miss rate." 13,58 For example, one study concludes that "the HEART pathway was associated with . death and myocardial infarction rates well below 1% among low-risk patients."…”

Section: Is the Rule's Performance Sufficiently Precise? (Noncompliant)mentioning

confidence: 99%

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A Methodological Appraisal of the HEART Score and Its Variants

Green

Schriger

2021

Annals of Emergency Medicine

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We performed a methodological appraisal of the history, electrocardiogram, age, risk factors, and troponin (HEART) score and its variants in the context of Annals of Emergency Medicine's methodological standards for clinical decision rules. We note that this chest pain risk stratification tool was not formally derived, omits sex and other known predictors, has weak interrater reliability, and its 0, 1, and 2 score weightings do not align with their known predictivities. Its summary performance (pooled sensitivities of 96% to 97% with lower confidence interval bounds of 93% to 94%) is below that which emergency physicians state a willingness to accept, below the 98% sensitivity exhibited by baseline practice without the score, and below the 1% to 2% acceptable miss threshold specified by the American College of Emergency Physicians chest pain policy. Two variants (HEART Pathway, HEART-2) have the same inherent structural limitations and demonstrate slightly better but still suboptimal sensitivity. Although a simple prediction tool for chest pain outcomes is appealing, we believe that the widespread use of the HEART score and its variants should be reconsidered. [

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Section: Is the Rule's Performance Sufficiently Precise? (Noncompliant)mentioning

confidence: 92%

Section: Is the Rule's Performance Sufficiently Precise? (Noncompliant)mentioning

confidence: 99%

A Methodological Appraisal of the HEART Score and Its Variants

Green

Schriger

2021

Annals of Emergency Medicine

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“…They can be also useful in detecting damage to cardiomyocytes in, among others, massive pulmonary embolism with accompanying right ventricular overload. An increase in cTn levels in patients with stable coronary arterial disease indicates an increased risk of cardiovascular death [1,2]. A false positive result may be caused by the presence of rheumatoid factor or heterophilic antibodies [3,4].…”

Section: Introductionmentioning

confidence: 99%

Troponin Levels in Patients in Acute Phase of Stroke

Dziadkowiak¹

2018

J Cardiovasc Med Cardiol

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Background and Purpose: The purpose of this study was to assess the correlation of cTn levels in the acute phase of ischemic stroke with the extent of stroke, the degree of disability assessed on the modifi ed Rankin Scale, and their prognostic signifi cance. Methods: Patients were divided into 3 groups: (A) ischemic strokes, (B) ischemic strokes followed by hemorrhagic transformation, and (C) hemorrhagic strokes, excluding patients with symptoms of acute coronary syndrome. Cardiac troponin levels (cTn) were determined by venipuncture using the Abbott ARCHITECT STAT hs Troponin-I assay. Results: Seventy-four percent of the patients (128/173) were diagnosed with ischemic stroke, 14% (24/173) with ischemic stroke followed by hemorrhagic transformation, and 12% (21/173) with hemorrhagic stroke. The mean troponin level was 0.21 ± 1.15 ng/mL in the whole group (from 0 up to 12.4 ng/mL), while in the group with ischemic stroke the mean troponin level was 0.15 ± 076 ng/mL (from 0 up to 7.9 ng/mL). In 79/128 patients with ischemic stroke, troponin values were normal. Troponin levels were signifi cantly correlated with the modifi ed Rankin Scale on admission and on the day of discharge (p = 0.0001). Hyperlipidemia present in 104 patients had a statistically signifi cant effect on statistically higher troponin levels (0.15 ± 0.80 ng/mL). In 48% of the cases, vascular lesions involved the vascular area of the middle cerebral artery (83 patients), while the rarest ones were in the basal ganglia area (4 patients). In the case of cerebellum changes, statistically signifi cantly lower troponin levels were found than in the other groups (p = 0.050). Conclusions: A moderate increase in troponin was observed in patients with cerebral stroke. Elevated troponin levels indicated the lesion size and correlated with the degree of disability. High troponin levels can be a prognostic factor in the course of stroke.

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Comparing the Modified History, Electrocardiogram, Age, Risk Factors, and Troponin Score and Coronary Artery Disease Consortium Model for Predicting Obstructive Coronary Artery Disease and Cardiovascular Events in Patients With Acute Chest Pain

Teressa

Bhasin

Noack

et al. 2019

Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine

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The objective of this study was to compare the History, Electrocardiogram, Age, Risk factors, and Troponin (HEART) score and clinical coronary artery disease (CAD) consortium (CADC) model for predicting obstructive CAD (≥50% stenosis on coronary computed tomographic angiography) and 30-day major adverse cardiovascular events (MACE, composite of acute myocardial infarction, revascularization, and mortality). We studied 1981 patients with no known CAD who presented with acute chest pain and had negative initial troponin and electrocardiogram. Chest pain was classified as typical, atypical, and nonanginal and used to score the history component of the modified HEART score. The C-statistic for predicting obstructive CAD was 0.747 [95% confidence interval (CI), 0.712–0.783] for the HEART score and 0.792 (95% CI, 0.762–0.823) for the CADC model (P = 0.0005). The C-statistic for predicting 30-day MACE was 0.820 (95% CI, 0.774–0.864) for the HEART score and 0.850 (95% CI, 0.800–0.891) for the CADC model (P = 0.11). Among the 48.3% of patients for whom the CADC model predicted ≤5% probability of obstructive CAD, the observed 30-day MACE was 0.6%; among the 48.9% of patients for whom the HEART score was ≤2, the 30-day MACE was 0.6%. In conclusion, the CADC model was more effective at predicting obstructive CAD compared to the HEART score. The HEART score and CADC model were equally effective to safely identify low-risk patients by achieving <1% missed 30-day MACE.

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HEART Failure? Episodes of Missed Major Cardiac Events When Applying the HEART Pathway to an Observation Unit Population

Cited by 4 publications

References 25 publications

A Methodological Appraisal of the HEART Score and Its Variants

A Methodological Appraisal of the HEART Score and Its Variants

Troponin Levels in Patients in Acute Phase of Stroke

Comparing the Modified History, Electrocardiogram, Age, Risk Factors, and Troponin Score and Coronary Artery Disease Consortium Model for Predicting Obstructive Coronary Artery Disease and Cardiovascular Events in Patients With Acute Chest Pain

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