Prognostic Utility of a Modified HEART Score in Chest Pain Patients in the Emergency Department

Abstract

Background— The TRAPID-AMI trial study (High-Sensitivity Troponin-T Assay for Rapid Rule-Out of Acute Myocardial Infarction) evaluated high-sensitivity cardiac troponin-T (hs-cTnT) in a 1-hour acute myocardial infarction (AMI) exclusion algorithm. Our study objective was to evaluate the prognostic utility of a modified HEART score (m-HS) within this trial. Methods and Results— Twelve centers evaluated 1282 patients in the emergency department for possible AMI from 2011 to 2013. Measurements of hs-cTnT (99th percentile, 14 ng/L) were performed at 0, 1, 2, and 4 to 14 hours. Evaluation for major adverse cardiac events (MACEs) occurred at 30 days (death or AMI). Low-risk patients had an m-HS≤3 and had either hs-cTnT<14 ng/L over serial testing or had AMI excluded by the 1-hour protocol. By the 1-hour protocol, 777 (60%) patients had an AMI excluded. Of those 777 patients, 515 (66.3%) patients had an m-HS≤3, with 1 (0.2%) patient having a MACE, and 262 (33.7%) patients had an m-HS≥4, with 6 (2.3%) patients having MACEs ( P =0.007). Over 4 to 14 hours, 661 patients had a hs-cTnT<14 ng/L. Of those 661 patients, 413 (62.5%) patients had an m-HS≤3, with 1 (0.2%) patient having a MACE, and 248 (37.5%) patients had an m-HS≥4, with 5 (2.0%) patients having MACEs ( P =0.03). Conclusions— Serial testing of hs-cTnT over 1 hour along with application of an m-HS identified a low-risk population that might be able to be directly discharged from the emergency department.

A Novel Index for Prompt Prediction of Severity in Patients with Unstable Angina Pectoris

“…In another recent study, the PLR level was reported to be independently associated with the GENSINI score together with white blood cell (WBC) count, age, and low high-density lipoprotein (HDL) in multivariate analysis [11]. e m-HS includes elements of the history, ECG, age, and risk factors [8]. However, in the original HS, cTn levels were considered in a way that allowed a patient with an elevated cTn to be evaluated as low-risk [8].…”

“…However, in the original HS, cTn levels were considered in a way that allowed a patient with an elevated cTn to be evaluated as low-risk [8]. In a previous study, it was suggested that when normal serial cTn values are combined with the HS, a very low-risk patient population can be identified, which could be discharged from the ED without further testing [8]. Low-risk patients (a score of ≤3) have been reported to have a low (1.7%) MACE rate [9].…”

“…e acronym m-HS is an abbreviation of the four parameters evaluated [5]: history (highly suspicious-2 points; moderately suspicious-1 point; slightly suspicious-0 points), ECG (significant STdepression-2 points; nonspecific repolarization According to the total score applied, patients with UAP were separated as m-HS ≤3 low risk and m-HS ≥4 high risk of a MACE, within 6 weeks after presentation at the ED [8]. Lower scores (m-HS ≤ 3) led to a recommendation of early discharge, and high scores (HS ≥ 4) suggested clinical observation or performance of noninvasive investigations and admission for more invasive strategies [8]. Stress testing was applied to patients with UAP with m-HS ≤3.…”

“…ere are many risk stratification scores for ACS, but with the exception of the modified-heart score (m-HS), scoring systems are time-consuming and can delay treatment in patients with ACS caused by myocardial damage due to low ejection fraction. M-HS is a rapid risk stratification tool, designed by ED physicians to evaluate patients with chest pain according to their short-term risk of major adverse cardiac event (MACE, defined as acute myocardial infarction (AMI), need for percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG), and death within 6 weeks) to help identify low-risk patients, suitable for earlier ED discharge within 30 days of index ED visit [8,9]. However, the original HS included cTn levels in the score in a way that allowed a patient with an elevated cTn to be considered low-risk [8].…”

“…M-HS is a rapid risk stratification tool, designed by ED physicians to evaluate patients with chest pain according to their short-term risk of major adverse cardiac event (MACE, defined as acute myocardial infarction (AMI), need for percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG), and death within 6 weeks) to help identify low-risk patients, suitable for earlier ED discharge within 30 days of index ED visit [8,9]. However, the original HS included cTn levels in the score in a way that allowed a patient with an elevated cTn to be considered low-risk [8]. Generally, highrisk patients are admitted to the cardiology or medical wards and those at low risk are managed in an observation unit or sent home.…”