Sex and race differences in safety and effectiveness of the HEART pathway accelerated diagnostic protocol for acute chest pain

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

doi:10.1016/j.ahj.2020.11.005

Cited by 9 publications

(9 citation statements)

References 36 publications

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“…24,25 Women are more likely to be classified as low-risk by HEART. 25,27 HEART also omits consideration of the promptness and quality of outpatient follow-up which, as noted earlier, can vary substantially by patient and setting and should reasonably impact the magnitude of the workup during the ED visit.…”

Section: Were All Potentially Important Predictor Variables Included? (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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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: Were All Potentially Important Predictor Variables Included? (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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“…2 However, the HEART score method has been shown to better discriminate patients possessing lower-risks than the TIMI or other mea-sures for major adverse cardiac events. [16][17][18][19][20] It has been earlier acknowledged that such standardized score methods could actually introduce potential biases on the final results of study groups. 21,22 It will also remain quite difficult for researchers to precisely tease out what chest pain management patterns may be primarily attributable to variations in provider ordering, patient preferences, or other unmeasured factors.…”

Section: Discussionmentioning

confidence: 99%

Racial Variations in Emergency Department Management of Chest Pain in a Community-based Setting

Greenberg

Schultz

Cobb

et al. 2022

Spartan Medical Research Journal

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INTRODUCTION Chest pain is one of the most common chief presenting complaints occurring in most Emergency Departments. The HEART score is a validated risk stratification tool commonly used to evaluate chest pain. Prior research has demonstrated the existence of complex racial variations in health care, specifically in what tests are ordered (or accepted by patients) during evaluation and treatment of cardiac disease. The authors hypothesized that chest pain management (i.e., disposition to hospital/observation unit and rates of stress testing) patterns and longitudinal outcomes (i.e., death and 30-day readmission) would occur differently in African Americans despite systematic use of the HEART score. METHODS Funded by the Statewide Campus System, this study was comprised of a retrospective chart review of a sample of eligible patients presenting with chest pain to the authors’ 345-bed community-based Michigan hospital. RESULTS Of the 1,412 eligible sample patients, 886 (63%) reported their racial affiliation as White, 473 (33%) African-American, and 53 (4%) “Other”. The average HEART score in Whites was 3.92 (SD = 1.89) compared to 3.31 (SD = 1.79) in African-Americans, (p < 0.01, 95% CI: 0.40-0.82). However, White patients’ odds of admission to observation or inpatient was 1.49 times higher (95% CI: 1.04 - 2.15), with every unit increase in HEART score increasing the odds ratio of admission by 3.24 times (95% CI: 2.79 - 3.76). White patients were also 2.37 times more likely to receive (or accept) stress tests than African American patients (95% CI: 1.41 - 3.88). Only five (0.01%) of 458 White patients with HEART score between 4 and 6 experienced 30-day readmission or death whereas seven (0.04%) of 193 African-American patients experienced these outcomes (p = 0.04 with OR 3.40, 95% CI: 1.07 - 10.9). CONCLUSIONS Although the authors were unable to precisely distinguish the provider (e.g., desire to order testing) and patient-driven (e.g., desire to accept testing) factors likely to contribute to measured differences, these results suggest continued complex racial variations concerning hospital admission and stress testing in chest pain patients. Further studies are needed to analyze potential systems or subject-level factors influencing the multi-dimensional phenomenon of chest pain management across racial affiliation.

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“…We have a forthcoming subgroup analysis demonstrating its safety among women and nonwhite patients. 4 However, the HEART Pathway has yet to be evaluated in a Hispanic/Latinx population, which represented only 4.8% of our cohort. We look forward to high-quality clinical trials or cohort studies evaluating the HEART Pathway in other populations.…”

Section: Correspondencementioning

confidence: 99%

“…Head-to-head meta-analysis was conducted with a random-effects model because some clinical heterogeneities existed in the included randomized controlled trials. 1,4 Statistical heterogeneity was tested by I 2 . Pooled risk ratio of mortality may be seriously biased by clinical heterogeneity if I 2 is greater than 50% or P<.10 for the heterogeneity test.…”

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confidence: 99%

“…In general, ED high users are defined as those having greater than or equal to 4 ED visits in the past 12 months. 4 Patients with only one previous ED visit cannot be deemed high users. Although these patients accounted for a small portion of the study sample size and their exclusion might not have affected the overall accuracy of the study, emergency physicians might be more interested in knowing whether HEART criteria could also apply to these patients.…”

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