Not all HEART scores are created equal: identifying “low‐risk” patients at higher risk

Abstract

Objective: We sought to identify subgroups of "low-risk" HEART score patients (history, ECG, age, risk factors, and troponin) at elevated risk of acute myocardial infarction or death within 30 days. Methods: We performed a secondary analysis of prospective emergency department (ED) encounters for suspected acute coronary syndrome in a large health system with low-risk HEART scores (0-5 points). Logistic regression using the 5 components of the HEART score analyzed the increase risk attributable to points from each of the 5 score components. Results: Of 30,971 encounters among 28,992 unique patients, 135 (0.44%, 95% confidence interval [CI] = 0.37-0.51) experienced acute myocardial infarction or death.

A Methodological Appraisal of the HEART Score and Its Variants

“…A second regression study focused on a low-to mid-risk patients also noted substantial discordance between assigned scores and their predictivity. 44 The inherent mathematical assumption when adding 5 independent subscales into a total score is that each component point is of similar clinical impact relative to each of the others. Table 2 indicates that this is not the case for HEART.…”

The HEART Pathway: Just a HEART score permutation or the future of clinical decision rules?

“…This structural change to their implementation of the HEART score is supported by others as well with work by Ioannides et al 14 performed on a large prospectively collected sample of patients presenting to the ED with chest pain. While not an identical population, having only included those with HEART score between 0 and 5, they sought to evaluate whether subsets of patients within each risk strata have varying risks of MACE.…”

“…This is an empirical deviation from their initially proposed pathway that more closely resembled the original HEART score. 9 This structural change to their implementation of the HEART score is supported by others as well with work by Ioannides et al 14 performed on a large prospectively collected sample of patients presenting to the ED with chest pain. While not an identical population, having only included those with HEART score between 0 and 5, Supervising Editor: Dr. Paul Musey.…”