URGENT 1.5: diagnostic accuracy of the modified HEART score, with fingerstick point-of-care troponin testing, in ruling out acute coronary syndrome

Abstract

Background The HEART score is a validated risk stratification tool for chest pain patients presenting to the emergency department and was recently investigated for implementation in a pre-hospital setting. Fingerstick (capillary blood) point-of-care (POC) troponin testing enables quick measurements outside the hospital and seems easier to implement than the current venous blood sampling techniques. This study investigates the diagnostic accuracy of the modified HEART score, integrating fingerstick POC troponin testing, in ruling out acute coronary syndrome (ACS). Methods The data of 96 patients with chest pain, included in a study investigating a novel POC troponin device under development at the cardiac emergency department, were analysed retrospectively. Based on the patients’ admission data and capillary POC high-sensitivity troponin I (hs-cTnI) results, the modified HEART score was determined. The outcome measure, for evaluating the diagnostic accuracy of the modified HEART score, was the occurrence of ACS. Results Of the total study population, 33 patients (34%) were diagnosed with ACS. Seventeen patients (18%) were classified as low risk (0–3 points) and one patient (6%) in this group was diagnosed with ACS. The sensitivity and negative predictive value of the modified HEART score was 97.0 and 97.6%, respectively. Conclusion The modified HEART score, integrating capillary POC hs-cTnI results, is a promising tool for ruling out ACS in patients with chest pain presenting to the cardiac emergency department. These results encourage prospective investigation into the integration of fingerstick POC troponin testing in the modified HEART score in a pre-hospital setting.

Applying the HEART score is safe and saves

“…Therefore we concur with Koper et al. [ 1 ] that the next step should be a general practitioner and ambulance staff based study potentially using new home-based ECG technology together with the fingertip POC troponin assessment. Whether the same kit can be used for both sexes needs to be clarified, as there are different thresholds for troponin that are relevant for risk classification [ 10 ].…”

“…Even in the small study reported by Koper et al. [ 1 ], in patients with a low-risk score a very high sensitivity (97%) and negative predictive value (97.6%) are reported using the modified HEART score, and only one ACS was missed. Importantly, the study included a point-of-care (POC)-based test assessed by a fingertip troponin I measurement suitable for the home situation, which was, however, obtained at the ED.…”

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Koper et al performed an encouraging study (Urgent 1.5) to fine-tune the well-established HEART score [1], which was previously initiated and validated by the cardiologist Jacob Six. He and several PhD students looked at various aspects of the score, which was based on clinical intuition and experience to rule out an acute coronary syndrome (ACS).

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“…Even in low-risk patients many expensive diagnostic tests are performed which are time consuming and put the patient at risk during invasive procedures [3]. Even in the small study reported by Koper et al [1], in patients with a low-risk score a very high sensitivity (97%) and negative predictive value (97.6%) are reported using the modified HEART score, and only one ACS was missed. Importantly, the study included a point-of-care (POC)-based test assessed by…”

“…There are several suggestions based on this study [ 1 ]. Importantly, this is further confirmation that in chest pain patients the HEART score is extremely useful in defining low-risk patients in whom a wait-and-see policy is very safe.…”