In the JournalsPerspective

HEART score to assess patients with chest pain underutilized in EDs

Using the History, ECG, Age, Risk factors and initial Troponin, or HEART, score during initial assessment of patients with chest pain is safe; however, physicians did not always follow recommendations based on a patient’s score, according to recent findings.

“The HEART score... provides the physician with a formal recommendation for admission, observation or discharge in individual patients... [and] has shown promising results in external validation studies in various countries and hospital settings,” Judith M. Poldervaart, MD, PhD, from University Medical Center Utrecht and Diakonessehuis Utrecht in the Netherlands, and colleagues wrote. “Still, clinicians remain uncertain about safety when using the HEART score in daily practice because its effect has not yet been evaluated.”

Researchers evaluated if using the HEART score would result in reduced burden of care, hospitalizations and health care costs without increasing the occurrence of adverse cardiac events. They performed a stepped-wedge, cluster randomized trial to examine unselected patients with chest patients presenting at nine Dutch hospital EDs between July 1, 2013 and Aug. 31, 2014.

All hospitals began intervention with usual care, defined as daily practice of an attending physician to assess patients with chest pain. Then, researchers would randomly assign one hospital to switch to “HEART care,” routine initial work-up plus formal calculation of the total HEART score linking to specific recommendations for further management, every 6 weeks. They set a noninferiority margin of a 3% absolute increase in major adverse cardiac events (MACEs) within 6 weeks.

Out of 3,648 patients included in the study, 1,827 received usual care and 1,821 received HEART-directed care. During HEART-directed care, the results showed 6-week incidence of MACEs was 1.3% lower than for patients receiving usual care (upper limit of the 1-sided 95% CI, 2.1%). The investigators found that in low-risk participants, incidence of MACE was 2% (95% CI, 1.2-3.3). They observed no statistical differences in early discharge, readmissions, recurrent ED visits, outpatient visits or visits to general practitioners between the HEART-directed care and usual care groups. There was a 41% nonadherence to HEART care recommendations in the low-risk group, suggesting that these results may be limited because physicians did not always adhere to admission and diagnostic test recommendations in patients classified as low risk by the HEART score.

“The HEART score is an accurate risk stratification instrument and is safe to use when assessing patients with chest pain in the ED,” Poldervaart and colleagues wrote. “Hesitance to refrain from admission and testing in patients with low scores could explain the small effect on health care costs. Such barriers should be addressed for patient management to better adhere to directive use of the HEART score.” – by Savannah Demko

Disclosure: Poldervaart reports no relevant financial disclosures. Please see the full study for a complete list of all other authors’ relevant financial disclosures.

 

Using the History, ECG, Age, Risk factors and initial Troponin, or HEART, score during initial assessment of patients with chest pain is safe; however, physicians did not always follow recommendations based on a patient’s score, according to recent findings.

“The HEART score... provides the physician with a formal recommendation for admission, observation or discharge in individual patients... [and] has shown promising results in external validation studies in various countries and hospital settings,” Judith M. Poldervaart, MD, PhD, from University Medical Center Utrecht and Diakonessehuis Utrecht in the Netherlands, and colleagues wrote. “Still, clinicians remain uncertain about safety when using the HEART score in daily practice because its effect has not yet been evaluated.”

Researchers evaluated if using the HEART score would result in reduced burden of care, hospitalizations and health care costs without increasing the occurrence of adverse cardiac events. They performed a stepped-wedge, cluster randomized trial to examine unselected patients with chest patients presenting at nine Dutch hospital EDs between July 1, 2013 and Aug. 31, 2014.

All hospitals began intervention with usual care, defined as daily practice of an attending physician to assess patients with chest pain. Then, researchers would randomly assign one hospital to switch to “HEART care,” routine initial work-up plus formal calculation of the total HEART score linking to specific recommendations for further management, every 6 weeks. They set a noninferiority margin of a 3% absolute increase in major adverse cardiac events (MACEs) within 6 weeks.

Out of 3,648 patients included in the study, 1,827 received usual care and 1,821 received HEART-directed care. During HEART-directed care, the results showed 6-week incidence of MACEs was 1.3% lower than for patients receiving usual care (upper limit of the 1-sided 95% CI, 2.1%). The investigators found that in low-risk participants, incidence of MACE was 2% (95% CI, 1.2-3.3). They observed no statistical differences in early discharge, readmissions, recurrent ED visits, outpatient visits or visits to general practitioners between the HEART-directed care and usual care groups. There was a 41% nonadherence to HEART care recommendations in the low-risk group, suggesting that these results may be limited because physicians did not always adhere to admission and diagnostic test recommendations in patients classified as low risk by the HEART score.

“The HEART score is an accurate risk stratification instrument and is safe to use when assessing patients with chest pain in the ED,” Poldervaart and colleagues wrote. “Hesitance to refrain from admission and testing in patients with low scores could explain the small effect on health care costs. Such barriers should be addressed for patient management to better adhere to directive use of the HEART score.” – by Savannah Demko

Disclosure: Poldervaart reports no relevant financial disclosures. Please see the full study for a complete list of all other authors’ relevant financial disclosures.

 

    Perspective

    The randomized study by Poldervaart et al, including more than 3,500 patients is by far the largest trial of the HEART score in evaluating patients with possible acute myocardial infarction (AMI) in the ED. The easy-to-calculate HEART score incorporates elements of the history, ECG, and cardiac troponin levels in evaluating patients with possible AMI.

    What are the practical implications of this trial for practicing physicians? The study confirms that patients with a low HEART score (≤ 3) are very low risk with only 5/715 (0.7%) “hard” adverse events (death or AMI) occurring at 6 weeks. In the group randomized to use of the HEART score, 39% had a HEART score ≤ 3. If patients had a HEART score ≤ 3 and normal serial troponin values there were only two “hard” adverse events. When physicians see patients with unclear symptoms that may represent AMI, they can be told that they may be quickly evaluated in the ED with the HEART score and serial troponin levels. These individuals can be discharged without prolonged observation periods and immediate stress testing for further out-patient evaluation, which is more cost-effective than present practice. With newer, more sensitive troponin assays the serial testing can be done in as little as 1 hour with much less inconvenience to patients. 

    • James K. McCord, MD
    • Henry Ford Heart and Vascular Institute

    Disclosures: McCord reports receiving research funding from Roche Diagnostics, Siemens Diagnostics and Abbott Diagnostics and being a consultant for Roche and Siemens.