The HEART Pathway Randomized Trial

Mahler, Simon A.; Riley, Robert F.; Hiestand, Brian; Russell, Gregory B.; Hoekstra, James W.; Lefebvre, Cedric W.; Nicks, Bret A.; Cline, David; Askew, Kim; Elliott, Stephanie; Herrington, David M.; Burke, Gregory L.; Miller, Chadwick D.

doi:10.1161/circoutcomes.114.001384

Cited by 318 publications

(233 citation statements)

References 34 publications

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“…There has now been a small RCT using a modified version of the HEART score that used structured criteria to categorize history and excludes patients from being classified as low risk if there is a positive troponin result from blood sampling at 0 and 3 hours from arrival at the ED. 70 In this study, the prevalence of major adverse cardiac events was 6%, and the sensitivity for major adverse cardiac events for 141 patients randomized to the modified HEART pathway was 100%.…”

Section: Combining Troponin With Risk Scoring Systems For Acceleratedmentioning

confidence: 69%

“…[61][62][63][64][65][66][67][68][69][70][71][72][73][74][75][76] Although most of the research in this area is observational, there have been 2 single-center RCTs, and there has been widespread implementation of such strategies in Australasia. The Australian state of Queensland and the country of New Zealand, with combined populations of nearly 10 million people, now have fully adopted accelerated diagnostic pathways.…”

Section: Combining Troponin With Risk Scoring Systems For Acceleratedmentioning

confidence: 99%

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State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

2016

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ABSTRACT:It is well established that clinicians cannot use clinical judgment alone to determine whether an individual patient who presents to the emergency department has an acute coronary syndrome. The history and physical examination do not distinguish sufficiently between the many conditions that can cause acute chest pain syndromes. Cardiac risk factors do not have sufficient discriminatory ability in symptomatic patients presenting to the emergency department. Most patients with non-ST-segment-elevation myocardial infarction do not present with electrocardiographic evidence of active ischemia. The improvement in cardiac troponin assays, especially in conjunction with well-validated clinical decision algorithms, now enables the clinician to rapidly exclude myocardial infarction. In patients in whom unstable angina remains a concern or there is a desire to evaluate for underlying coronary artery disease, coronary computed tomography angiography can be used in the emergency department. Once a process that took ≥24 hours, computed tomography angiography now can rapidly exclude myocardial infarction and coronary artery disease in patients in the emergency department.A bout 20 million patients present with symptoms possibly suggestive of acute coronary syndrome (ACS) to emergency departments (ED) in North America and Europe each year.1-3 Patients with ACS and acute myocardial infarction (AMI) present with a wide variety of symptoms such as chest pain, shortness of breath, weakness, nausea, vomiting, and even fatigue, making the diagnosis difficult. Demographics, cardiac risk factors, chest pain characteristics, and physical examination can assist disposition decisions but are insufficient to identify who does and does not have an ACS.4-7 Some patients may have objective evidence of a clearcut diagnosis, but the majority do not. 8 The majority ultimately will be found not to have ACS, but symptoms caused by noncardiac and often benign disorders such as musculoskeletal pain, pleuritis, or gastroesophageal reflux make the rapid rule-out of ACS more difficult and result in huge medical expenses. Safe and early rule-out of ACS contributes to more efficient and high-value healthcare delivery. History And PHysicAl ExAminAtionClinical features, alone or in combination with an ECG, are poorly predictive for AMI (Table 1). 9,10 In addition, they have variable reliability. Features classically associated with a lower probability of AMI such as pleuritic, positional, and sharp chest pain have poor to fair interphysician reliability (κ=0.27-0.44), 11 whereas high-risk features (radiation to left arm, substernal location, and history of AMI) are more reliable (κ=0.74-0.89). 11Traditional cardiac risk factors, derived from population-based longitudinal cohort studies of asymptomatic patients, are poor predictors of risk for AMI or ACS in symptomatic patients in the ED. 6,7 Similarly, the physical examination seldom is useful for distinguishing patients with ACS from patients with noncardiac chest pain.Trials of medications, onc...

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Section: Combining Troponin With Risk Scoring Systems For Acceleratedmentioning

confidence: 69%

Section: Combining Troponin With Risk Scoring Systems For Acceleratedmentioning

confidence: 99%

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

2016

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“…Mahler et al added a repeated troponin measurement at 3 hours to the HEART score (HEART Pathway) to increase the NPV. They were able to identify 39.7% of patients for early discharge (HEART score 0–3 and negative serial troponins) with an NPV of 100% and a PPV of 10.7% 33. The drawback of this approach is that it requires serial troponin testing.…”

Section: Discussionmentioning

confidence: 99%

Sex‐Based Differences in the Performance of the HEART Score in Patients Presenting to the Emergency Department With Acute Chest Pain

Bank

Hoog

Kleijn

et al. 2017

JAHA

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BackgroundSex‐based differences in clinical presentation, pathophysiology, and outcomes of patients with acute chest pain are increasingly being recognized, but are not implemented in guidelines and clinical prediction tools. We evaluated the performance of the HEART score in women versus men, because sex‐based differences may exist among the algorithm's components: history, electrocardiogram, age, risk factors, and admission troponin level.Methods and ResultsThe HEART score was retrospectively assessed in 831 women and 1084 men presenting to the emergency department with acute chest pain, assigning patients to the low‐, intermediate‐, or high‐risk category for the occurrence of major adverse cardiac events (MACE) within 6 weeks. MACE, consisting of myocardial infarction, coronary revascularization, and all‐cause death, also included events during index visit. Six‐week MACE rates were 2 times lower in women than men (10.0% versus 20.8%; P<0.01). Despite similar discriminatory accuracy of the HEART score among women and men (c‐statistic, 0.80 [0.75–0.84] versus 0.77 [0.74–0.81]; P=0.43), 6‐week MACE rates were significantly lower in women than men across all HEART risk categories: 2.1% versus 6.5% (P<0.01) in the low‐risk category, 12.7% versus 21.3% (P<0.01) in intermediate‐risk category, and 53.1% versus 77.0% (P=0.02) in the high‐risk category. The HEART score‐adjusted risk ratio for men was 1.6 (1.3–2.0; P<0.01).ConclusionsThe markedly higher 6‐week MACE risk in men across all HEART risk categories should be taken into account when using the HEART score to guide clinical decision making; early discharge with a low‐risk HEART score appears less safe for men than women with acute chest pain.

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“…ESCALA HEART (14,15,16,17) ESCALA HEART PARA DOLOR TORÁCICO La escala HEART (por sus siglas en inglés: History, EKG, Age, Risk factors, Troponin) ha sido validada por varios estudios obteniendo una sensibilidad y especificidad de acuerdo a su puntaje. Sirve para calcular la probabilidad de padecer de enfermedad coronaria.…”

Section: Escalas Diagnósticasunclassified

Enfermedad coronaria basada en la evidencia

Ferreira

2017

carta comunitaria

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INTRODUCCIÓNAprender y entender, son conceptos bien diferentes. Entender determina comprender, incluso asimilar conceptos pero, de ahí, a aprender, existe una gran distancia. Aprender es aplicar lo que se entiende, es tomar el concepto y usarlo para la vida.Este documento forma parte de la sección que hemos denominado La lección de Medicina. Una vez más, el profesor Bernal nos ha construido un hermoso material donde usa buena parte de su capacidad didáctica para hacernos entender, en esta ocasión, conceptos básicos acerca de la enfermedad coronaria. Nos pone de manifiesto cómo se revisa y se reconoce el origen de las fuentes. Nos ayuda a entender una serie de conceptos elementales en torno al dolor torácico y nos expone una sencilla clasificación. Nos hace entender la importancia de los diagnósticos diferenciales, usando precisamente como ejemplo dicho dolor. Nos introduce en las anginas torácicas y en los movimientos enzimáticos cuando las coronarias obstruidas resienten al miocardio, todo para resaltar las manifestaciones más frecuentes, vistas bajo la sensibilidad y la especificad a través de los cual nos invita a hacer diagnósticos más precisos, acercándonos a ese maravilloso mundo de la Medicina Basada en la Evidencia. Nos pareció que puso toda su pericia didáctica y la concretó en este maravilloso ejemplo.Esperamos que ustedes, nuestros lectores, entiendan esta lección y luego la apliquen a otras áreas. Con el fin de orientar su proceso de aprendizaje, se harán algunas preguntas. Les pedimos que al responderlas, pongan la referencia de donde obtuvieron la respuesta. Se trata de una de las habilidades que debemos "rutinizar" en todo proceso de revisión, ¿no les parece?Como siempre, ¡bienvenidos y feliz aprendizaje! ContextoEn la consulta médica de los servicios de urgencias, el dolor torácico es una causa frecuente de la cual se derivan patologías como la enfermedad coronaria. Las enfermedades cardiovasculares siguen siendo la principal causa de muerte en el mundo (1). Según estadísticas de la American Heart Association, en Estados Unidos 17,6 millones de personas tienen enfermedad coronaria. The Global Burden of Disease Study 2013 estima que 17,3 millones de muertes en el † † † † † † MD. Familiar Integral. Profesor FUJNC -gonzalo.bernal@juanncorpas.edu.co mundo se relacionan con enfermedad coronaria. Según el estudio de Framingham la incidencia de eventos ateromatosos en la población de 35 a 64 años se presenta con una frecuencia de 12 hombres y 5 mujeres por cada 1000 personas, respectivamente, y, en las edades de 65 años a 94 años, se presentan 27 casos en hombres contra 16 en mujeres por cada 100.000 personas.

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The HEART Pathway Randomized Trial

Cited by 318 publications

References 34 publications

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes

Sex‐Based Differences in the Performance of the HEART Score in Patients Presenting to the Emergency Department With Acute Chest Pain

Enfermedad coronaria basada en la evidencia

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