Mean HEART scores for hospitalized chest pain patients are higher in more experienced providers

Dubin, J.; Kiechle, Eric S.; Wilson, Matt; Timbol, Christian; Bhat, Rahul; Milzman, David

doi:10.1016/j.ajem.2016.10.037

Cited by 13 publications

(3 citation statements)

References 16 publications

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“…It is possible that these cases could be due to undercoding of the HEART score during chart review, although they could also represent actual ‘false-negatives,’ as perfect discrimination cannot be a realistic expectation of any risk-stratification tool, including the HEART pathway. Examining the experience levels of emergency physicians caring for this group of patients admitted despite low HEART scores suggests that disposition decisions favoring admission may have been driven by a lower comfort level with either discharge or ED-based cardiac testing, which is consistent with prior work in this area [7,8]. In addition, less experienced emergency physicians may not be as familiar as their more experienced colleagues with the option of engaging the triage cardiologist to assist with arranging robust outpatient follow-up.…”

Section: Discussionsupporting

confidence: 70%

Potential impact of cardiology phone-consultation for patients risk-stratified by the HEART pathway

et al. 2019

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ObjectiveBedside consultation by cardiologists may facilitate safe discharge of selected patients from the emergency department (ED) even when admission is recommended by the History, Electrocardiogram, Age, Risk factors, Troponin (HEART) pathway. If bedside evaluation is unavailable, phone consultation between emergency physicians and cardiologists would be most impactful if the resultant disposition is discordant with the HEART pathway. We therefore evaluate discordance between actual disposition and that suggested by the HEART pathway in patients presenting to the ED with chest pain for whom cardiology consultation occurred exclusively by phone and to assess the impact of phone-consultation on disposition.MethodsWe performed a single-center, retrospective study of adults presenting to the ED with chest pain whose emergency physician had a phone consultation with a cardiologist. Actual disposition was abstracted from the medical record. HEART pathway category (low-risk, discharge; high-risk, admit) was derived from ED documentation. For discharged patients, major adverse cardiac events were assessed at 30 days by chart review and phone follow-up.ResultsFor the 170 patients that had cardiologist phone consultation, discordance between actual disposition and the HEART pathway was 17%. The HEART pathway recommended admission for nearly 80% of discharged patients. Following cardiologist phone-consultation, 10% of high-risk patients were discharged, with the majority having undergone a functional study recommended by the cardiologist. At 30 days, discharged patients had experienced no episodes of major adverse cardiac events or rehospitalization for cardiac reasons.ConclusionFor patients presenting to the ED with chest pain, cardiology phone-consultation has the potential to safely impact disposition, primarily by facilitating functional testing in high-risk individuals.

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Section: Discussionsupporting

confidence: 70%

Potential impact of cardiology phone-consultation for patients risk-stratified by the HEART pathway

et al. 2019

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“…For instance, studies have shown that more experienced providers may score patients higher than newer practitioners while cardiologists may be likely to score borderline risk patients lower than ED physicians. 15 , 16 …”

Section: Discussionmentioning

confidence: 99%

“…The nonspecific elements were initially defined as “… the absence of specific elements in terms of pattern of chest pain, onset and duration, relation with exercise, stress or cold, localization of pain, concomitant symptoms, and the reaction to sublingual nitrates.” 3 This HEART score category is the most subjective, creating the opportunity for inter-rater variability depending on which historical elements were elicited and in what way. 15 , 16 . Looking to reduce this subjectivity and related inconsistent application, Marchick et al.…”

Section: Historymentioning

confidence: 99%

The HEART score: A guide to its application in the emergency department

Brady

Souza

2018

Turkish Journal of Emergency Medicine

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Chest pain is one of the most common, potentially serious presenting complaints for adult emergency department (ED) visits. The challenge of acute coronary syndrome (ACS) identification with appropriate disposition is quite significant. Many of these patients are low risk and can be managed non-urgently in the outpatient environment; other patients, however, are intermediate to high risk for ACS and should be managed more aggressively, likely with inpatient admission and cardiology consultation. The HEART score, a recently derived clinical decision rule aimed at the identification of risk in the undifferentiated chest pain patient, is potentially quite useful as an adjunct to physician medical decision-making. The HEART score identifies patients at low, intermediate, and high risk for short-term adverse outcome resulting from ACS. As is true of all such clinical decision rules, the physician should consider the information provided the HEART score yet exercise clinical judgment in the ultimate determination of management strategy in the adult chest pain patient suspected of ACS.

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Reliability of the CARE rule and the HEART score to rule out an acute coronary syndrome in non-traumatic chest pain patients

et al. 2018

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In patients consulting in the Emergency Department for chest pain, a HEART score ≤ 3 has been shown to rule out an acute coronary syndrome (ACS) with a low risk of major adverse cardiac event (MACE) occurrence. A negative CARE rule (≤ 1) that stands for the first four elements of the HEART score may have similar rule-out reliability without troponin assay requirement. We aim to prospectively assess the performance of the CARE rule and of the HEART score to predict MACE in a chest pain population. Prospective two-center non-interventional study. Patients admitted to the ED for non-traumatic chest pain were included, and followed-up at 6 weeks. The main study endpoint was the 6-week rate of MACE (myocardial infarction, coronary angioplasty, coronary bypass, and sudden unexplained death). 641 patients were included, of whom 9.5% presented a MACE at 6 weeks. The CARE rule was negative for 31.2% of patients, and none presented a MACE during follow-up [0, 95% confidence interval: (0.0-1.9)]. The HEART score was ≤ 3 for 63.0% of patients, and none presented a MACE during follow-up [0% (0.0-0.9)]. With an incidence below 2% in the negative group, the CARE rule seemed able to safely rule out a MACE without any biological test for one-third of patients with chest pain and the HEART score for another third with a single troponin assay.

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Mean HEART scores for hospitalized chest pain patients are higher in more experienced providers

Cited by 13 publications

References 16 publications

Potential impact of cardiology phone-consultation for patients risk-stratified by the HEART pathway

Potential impact of cardiology phone-consultation for patients risk-stratified by the HEART pathway

The HEART score: A guide to its application in the emergency department

Reliability of the CARE rule and the HEART score to rule out an acute coronary syndrome in non-traumatic chest pain patients

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