Identification of very low-risk acute chest pain patients without troponin testing

Smith, Lane M.; Ashburn, Nicklaus P.; Snavely, Anna C.; Stopyra, Jason P.; Lenoir, Kristin M.; Wells, Brian J.; Hiestand, Brian; Herrington, David M.; Miller, Chadwick D.; Mahler, Simon A.

doi:10.1136/emermed-2020-209698

Cited by 21 publications

(30 citation statements)

References 27 publications

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“…The recently proposed strategy that a HEAR score less than or equal to 1, 30 independent of troponin, may be appropriate to identify low-risk patients who do not require further cardiac investigation was evaluated post hoc, along with the paramedic clinical interpretation of the history component of the HEART score as low risk in isolation. As requested during the review process, details of the nonadjudicated discharge diagnoses are also presented, as is information regarding those who experienced an important adjudicated endpoint after index hospital discharge, but within 30 days.…”

Section: Outcome Measuresmentioning

confidence: 99%

The Ambulance Cardiac Chest Pain Evaluation in Scotland Study (ACCESS): A Prospective Cohort Study

Cooper

Ferguson

Donaldson³

et al. 2021

Annals of Emergency Medicine

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To determine whether risk stratification in the out-of-hospital setting could identify patients with chest pain who are at low and high risk to avoid admission or aid direct transfer to cardiac centers.Methods: Paramedics prospectively enrolled patients with suspected acute coronary syndrome without diagnostic ST-segment elevation on the ECG. The History, ECG, Age and Risk Factors (HEAR) score was recorded contemporaneously, and out-of-hospital samples were obtained to measure cardiac Troponin I (cTnI) level on a point-of-care device, to allow calculation of the History, ECG, Age, Risk Factors, and Troponin (HEART) score. HEAR and HEART scores less than or equal to 3 and greater than or equal to 7 were defined as low and high risk for major adverse cardiac events at 30 days.Results: Of 1,054 patients (64 years [SD 15 years]; 42% women), 284 (27%) experienced a major adverse cardiac event at 30 days. The HEAR score was calculated in all patients, with point-of-care cTnI testing available in 357 (34%). A HEAR score less than or equal to 3 identified 32% of patients (334/1,054) as low risk, with a sensitivity of 84.9% (95% confidence interval [CI] 80.7% to 89%), whereas a score greater than or equal to 7 identified just 3% of patients (30/1,054) as high risk, with a specificity of 98.7% (95% CI 97.9% to 99.5%). A point-of-care HEART score less than or equal to 3 identified a similar proportion as low risk (30%), with a sensitivity of 87.0% (95% CI 80.7% to 93.4%), whereas a score greater than or equal to 7 identified 14% as high risk, with a specificity of 94.8% (95% CI 92.0% to 97.5%). Conclusion:Paramedics can use the HEAR score to discriminate risk, but even when used in combination with out-of-hospital point-of-care cTnI testing, the HEART score does not safely rule out major adverse cardiac events, and only a small proportion of patients are identified as high risk. [

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Section: Outcome Measuresmentioning

confidence: 99%

The Ambulance Cardiac Chest Pain Evaluation in Scotland Study (ACCESS): A Prospective Cohort Study

Cooper

Ferguson

Donaldson³

et al. 2021

Annals of Emergency Medicine

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“…Smith et al used a net reclassification index (NRI) to assess the incremental value of adding a troponin measurement for distinguishing low from high-risk patients [23]. They determined that the addition of a single troponin to a HEAR score of ≤ 1 did not significantly improve risk classification [11]. We did not perform this analysis because only one patient with HEAR ≤ 1 had a 30-day major adverse cardiac event, suggesting minimal incremental benefit of highsensitivity troponin measurement in patients with very low HEAR scores.…”

Section: Discussionmentioning

confidence: 99%

“…Recently, Smith et al proposed a modified version of the original HEART score, omitting the troponin component in an attempt to identify patients at such low risk of 30-day major adverse cardiac events that they may not require any biomarker testing at all (Appendix A, Table 4) [11]. In a secondary analysis of data from the HEART Pathway Implementation study [4,12] they tested the prognostic ability of very low HEAR scores in over 4,000 patients with symptoms of possible acute coronary syndromes and no known history of coronary artery disease.…”

Section: Introductionmentioning

confidence: 99%

“…In a secondary analysis of data from the HEART Pathway Implementation study [4,12] they tested the prognostic ability of very low HEAR scores in over 4,000 patients with symptoms of possible acute coronary syndromes and no known history of coronary artery disease. They found that a HEAR score ≤ 1 occurred in 9.0% and yielded a sensitivity of 97.8% (95% CI 94.5-99.4%) for 30-day major adverse cardiac events, suggesting that troponin testing is of low utility for this population [11]. Several studies have attempted to validate this strategy with promising results [13,14].…”

Section: Introductionmentioning

confidence: 99%

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External validation of a low HEAR score to identify emergency department chest pain patients at very low risk of major adverse cardiac events without troponin testing

2021

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Background The history, ECG, age, risk factor (HEAR) score has been proposed to identify patients at sufficiently low risk of acute coronary syndrome that they may not require troponin testing. The objective of this study was to externally validate a low HEAR score to identify emergency department (ED) patients with chest pain at very low risk of 30-day major adverse cardiac events (MACE). Methods This was a secondary analysis of a prospective cohort of patients requiring troponin testing to rule out myocardial infarction (MI) in a large urban ED. HEAR scores were calculated in two cohorts: (1) patients with no known history of coronary artery disease (CAD); and (2) all eligible patients. The proportion of patients classified as very low risk, sensitivity, specificity, predictive values and likelihood ratios at each cut-off were quantified for index acute myocardial infarction (AMI) and 30-day MACE at HEAR = 0 and HEAR ≤ 1 thresholds. Results Of the 1150 patients included in this study, 820 (71.3%) had no history of CAD, 97 (8.4%) had index AMI and 123 (10.7%) had 30-day MACE. In patients with no prior history of CAD, HEAR ≤ 1 identified 202 (24.6%) of patients as very low risk for 30-day MACE with 98.4% (95% CI 91.6-99.9%) sensitivity. Among all patients, HEAR ≤ 1 identified 202 (17.6%) patients as very low risk for 30-day MACE with 99.2% (95% CI 95.6-99.9%) sensitivity. Conclusions A HEAR score ≤ 1 can identify more than 17% of all patients as very low risk for index AMI and 30-day MACE and unlikely to benefit from troponin testing. Broad implementation of this strategy could lead to significant resource savings. Keywords HEAR score • Chest pain • Risk stratification RésuméContexte Le score HEAR (History, ECG, Age, Risk Factor) a été proposé pour identifier les patients présentant un risque suffisamment faible de syndrome coronarien aigu pour ne pas nécessiter de test à la troponine. L'objectif de cette étude était de valider à l'externe un faible score HEAR afin d'identifier les patients du service d'urgence (DE) souffrant de douleurs thoraciques à très faible risque d'événements cardiaques indésirables majeurs (MACE) de 30 jours. Méthodes Il s'agissait d'une analyse secondaire d'une cohorte prospective de patients nécessitant un test à la troponine pour exclure un infarctus du myocarde (IM) dans un grand service d'urgence urbain. Les scores HEAR ont été calculés dans deux cohortes : (1) les patients sans antécédents connus de maladie coronarienne (MC) ; et (2) tous les patients éligibles. La proportion de patients classés à très faible risque, la sensibilité, la spécificité, les valeurs prédictives et les rapports de vraisemblance à chaque seuil ont été quantifiés pour l'infarctus aigu du myocarde (IAM) de l'index et la MACE à 30 jours aux seuils HEAR = 0 et HEAR ≤ 1.

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“…By design, a troponin result is required for the HEART decision tool 18 to identify patients with an acceptably low rate of major adverse cardiac events (MACE). However, a recent study (n = 4979) 19 found that 9% of patients with HEAR score of 0 to 1 would not need troponin testing to achieve an acceptable MACE rate (<1%); therefore, 9.0% of troponin tests are "medically unnecessary. "…”

Section: Basic Definitions and Assumptionsmentioning

confidence: 99%

The “NUTS” statistic: Applying an EBM disease model to defensive medicine

Allen

Cai

Tepler

et al. 2021

J of Healthc Risk Manag

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Physicians believe that malpractice concerns result in unnecessary testing, and many emergency physicians state that avoiding malpractice is a contributing factor to ordering medically unnecessary tests. Unfortunately, defensive medicine does not come without possible harm to patients who may be subject to non-beneficial, downstream testing, procedures, and hospitalizations. We submit a novel statistic, "NUTS" or "Number of Unnecessary Tests to avoid one Suit. " We calculated a NUTS of 4737 for troponin testing in ED patients with suspected myocardial infarction, meaning a clinician will need to order 4737 medically unnecessary troponin tests to avoid one missed myocardial infarction lawsuit. The NUTS framework offers us an evidence-based lens to examine defensive medicine less superstitiously and more based on currently available data.

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Identification of very low-risk acute chest pain patients without troponin testing

Cited by 21 publications

References 27 publications

The Ambulance Cardiac Chest Pain Evaluation in Scotland Study (ACCESS): A Prospective Cohort Study

The Ambulance Cardiac Chest Pain Evaluation in Scotland Study (ACCESS): A Prospective Cohort Study

External validation of a low HEAR score to identify emergency department chest pain patients at very low risk of major adverse cardiac events without troponin testing

The “NUTS” statistic: Applying an EBM disease model to defensive medicine

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