The HEART score with high-sensitive troponin T at presentation: ruling out patients with chest pain in the emergency room

Abstract

The HEART score is a simple scoring system, ranging from 0 to 10, specifically developed for risk stratification of patients with undifferentiated chest pain. It has been validated for the conventional troponin, but not for high-sensitive troponin. We assess a modified version of the HEART score using a single high-sensitivity troponin T dosage at presentation, regardless of symptom duration, and with different ECG criteria to evaluate if the patients with a low HEART score could be safely discharged early. The secondary aim was to confirm a statistically significant difference in each HEART score group (low 0-3, intermediate 4-6, high 7-10) in the occurrence of major adverse cardiac events at 30 and 180 days. We retrospectively analyzed the HEART score of 1597 consecutive patients admitted to the Emergency Department of our Hospital for chest pain between January 1 and June 30, 2014. Of these, 190 did not meet the inclusion criteria and 29 were lost to follow-up. None of the 512 (37.2 %) patients with a low HEART score had an event within 180 days. The difference between the cumulative incidences of events in the three HEART score groups was statistically significant (P < 0.0001). We demonstrate that it might be possible to safely discharge Emergency Department chest pain patients with a low modified HEART score after an initial determination of high-sensitive troponin T, without a prolonged observation period or an additional cardiac testing.

Early Exclusion of Major Adverse Cardiac Events in Emergency Department Chest Pain Patients: A Prospective Observational Study

“…[28] A study by Santi et al found that a HEART score ≤3 had 100% sensitivity and 43.7% specificity when used to rule-out patients for 30-day MACE. [29] The sensitivities achieved are similar to our study while the higher specificities may again be due to younger patient groups in their studies. Different from these three studies, our study included all-cause mortality, suggesting that the combination of TIMI equals 0 and HEART score≤2 is not only safe for discharge without MACE within 30 days.…”

Prognostic Accuracy of the HEART Score for Prediction of Major Adverse Cardiac Events in Patients Presenting With Chest Pain: A Systematic Review and Meta‐analysis

“…Our search identified 778 citations (Figure ) and following removal of duplicates, we screened 557 studies, from which 62 studies underwent full‐text review. We included 29 distinct cohorts from 30 studies in the meta‐analysis . All included studies evaluated the prognostic accuracy of the HEART score using a low‐risk threshold (score between 0 and 3).…”

“…All included studies evaluated the prognostic accuracy of the HEART score using a low‐risk threshold (score between 0 and 3). Twenty‐one studies also evaluated the prognostic accuracy of the HEART score using a high‐risk threshold (score between 7 and 10) . Eight studies additionally evaluated the prognostic accuracy of a low‐risk TIMI (score of either 0 or 1) for prediction of MACE, while three evaluated the prognostic accuracy of a high‐risk TIMI (score of either 6 or 7) …”

“…Sixteen studies evaluated the HEART score for 30‐day incidence of MACE, while 13 evaluated the HEART score for 6‐week incidence of MACE . Most studies included only patients presenting with chest pain, while five studies included patients presenting with “suspected ACS.” In 14 studies, the ECG was interpreted by an ED physician, while in seven studies the ECG was specifically interpreted by a cardiologist . Four studies computed the HEART score using high‐sensitivity troponin assays, while the remaining studies used conventional troponin T or I assays (as used in the original study) …”

Determining whether A Low HEART Score Is Associated with Low Risk in Coronary Angiography Results: Validation of HEART Score Using Coronary Angiography Results

“…These two patients underwent CAG procedure irrespective of the HEART score owing to clinical concerns regarding persistent and typical chest pain. If a 1% range of MACE rate remains a major concern for discharging chest pain patients safely, clinicians in the ED could consider performing additional measures (such as a repeated high-sensitive cardiac troponin) to assist in determining HEART score [19].…”