A direct comparison of decision rules for early discharge of suspected acute coronary syndromes in the era of high sensitivity troponin

Abstract

HEART ≤3 or LOD HSTnT strategy rules out short and medium term myocardial infarction with ≥99.5% certainty, and short-term MACE with >99% certainty, allowing for early discharge of 53.4% and 36.9% respectively of suspected acute coronary syndrome. Adoption of either strategy has the potential to greatly reduce Emergency Room pressures and minimise follow-up investigations. Very early presenters (<3 h), due to limited numbers, are excluded from these conclusions.

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).…”

“…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) …”

The HEART score in the era of the European Society of Cardiology 0/1-hour algorithm

“…[5][6][7][8][9] The advent of high-sensitivity cardiac troponin assays has allowed for the development of several triage algorithms that can rapidly rule-out or rule-in suspected non-ST-segment elevation myocardial infarction (NSTEMI) during the index ED visit. [10][11][12][13][14][15][16][17][18] The 0/1-hour (0/1-h) algorithm uses high-sensitivity cardiac troponin T (hs-cTnT) concentrations at presentation and its absolute changes within the first hour to "rule-in" and "rule-out" suspected NSTEMIs and is recommended by the European Society of Cardiology (ESC) with a Class I recommendation. 19 The HEART score is a scoring system designed to aid in the risk stratification of patients with undifferentiated chest pain.…”

Prognostic significance and dynamic change of plasma macrophage migration inhibitory factor in patients with acute ST-elevation myocardial infarction

“…[ 5 ] Although clinical features, such as ST-segment deviation, elevation of cardiac markers and hemodynamic parameters may be useful as earliest markers for STEMI diagnosis prediction, the sensitivity and specificity is relatively poor, [ 6 ] and it still remains a challenge in the evaluation of patients with suspected acute myocardial infarction (AMI) despite the emergence of high sensitivity troponins or creatine kinase (CK)-MB. [ 7 ] Therefore, more specific and sensitive biomarkers are urgently needed to optimize the prediction and prognosis in STEMI.…”