Clinically relevant adverse cardiovascular events in intermediate heart score patients admitted to the hospital following a negative emergency department evaluation

Spiegel, Rory; Sutherland, Mark; Brown, Robert B.; Honasoge, Akilesh; Witting, Michael D.

doi:10.1016/j.ajem.2020.10.065

Cited by 10 publications

(6 citation statements)

References 27 publications

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“…Our study further affirms the low incidence of MACE for patients with normal hs‐trop and strengthens support for a discharge strategy when single or serial hs‐trop are normal. Evidence is mounting that normal hs‐trop values, even for patients who are moderate‐risk by HEART score, result in a MACE <1% and are amendable to outpatient pathways as opposed to hospital admissions 1,17,18 . Our results further strengthen support that when hs‐trop is normal, the 30‐day MACE rate is <1% and thus these patients may warrant consideration of outpatient management.…”

Section: Discussionsupporting

confidence: 69%

“…and are amendable to outpatient pathways as opposed to hospital admissions. 1,17,18 Our results further strengthen support that when hstrop is normal, the 30-day MACE rate is <1% and thus these patients may warrant consideration of outpatient management. However, consideration of the clinical context, including historical features such as known coronary artery disease or abnormal ECG findings, remains imperative and a normal hs-trop should not drive management in isolation.…”

Section: Limitationssupporting

confidence: 73%

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Multicenter analysis to assess risk of major adverse cardiac events in patients undergoing high‐sensitivity troponin testing in the emergency department

Serven,

Swayampakala,

Lesassier

et al. 2023

JACEP Open

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Study hypothesisOur objective was to evaluate 30‐day major adverse cardiac events (MACE) in emergency department (ED) patients with normal high‐sensitivity troponins (hs‐trop). We hypothesized that MACE rates would be <1% in patients with (1) two normal troponins regardless of change in troponin (delta) and (2) index hs‐trop below the limit of quantitation (LOQ) regardless of the institution modified HEART score.MethodsThis was a multicenter, retrospective, cohort study of adult patients who presented to 1 of 18 EDs between July 2020 and April 2021 with acute coronary syndrome as defined by an institutional‐modified HEART score completed by their treating physician or midlevel, no evidence of ST‐elevation myocardial infarction, and an index or serial gender‐adjusted hs‐trop within normal limits. The primary outcome was MACE within 30 days of index ED encounter. A detailed case review was then performed for those patients experiencing a MACE.ResultsOf the 9084 patients who had single or serial normal troponins, 31 (0.34%; confidence interval [CI] 0.23%–0.48%) experienced MACE. Of the 6140 patients with 2 normal hs‐trop and a delta (change in troponin) <4, 27 patients (0.44%; CI 0.29%–0.64%) experienced MACE. Only 1 of the 69 patients with 2 normal hs‐trop results but delta (change in troponin) ≥ 4 (1.45%; CI 0.04%–7.81%) suffered MACE. This patient was classified as non‐low risk by our institutional HEART score. Of 7498 patients with an index hs‐trop <LOQ, 14 (0.19%; CI 0.10%–0.31%) experienced MACE, with 57% (N = 8) deemed non‐low risk by HEART score.ConclusionPatients with 2 normal hs‐trop values in the ED are unlikely to suffer 30‐day MACE. Although it remains unclear whether patients with delta (change in troponin) ≥4 despite normal troponins will have a 30‐day MACE, this situation is rare. Additionally, a single index hs‐trop <6 ng/L demonstrated a low risk for 30‐day MACE independent of the institutional HEART score.

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Section: Discussionsupporting

confidence: 69%

Section: Limitationssupporting

confidence: 73%

Multicenter analysis to assess risk of major adverse cardiac events in patients undergoing high‐sensitivity troponin testing in the emergency department

Serven,

Swayampakala,

Lesassier

et al. 2023

JACEP Open

View full text Add to dashboard Cite

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“…evaluated a composite of life‐threatening arrhythmia, inpatient STEMI, cardiac or respiratory arrest, or death in intermediate HEART score patients admitted to the hospital after a negative ED evaluation. 25 This study showed a low cardiovascular risk for inpatient intermediate‐risk HEART score if there was a non‐ischemic ECG. Although all these studies have similar outcomes to our patient population, they did not look at the outcomes of early ED discharge for intermediate‐risk patients.…”

Section: Discussionmentioning

confidence: 63%

“…In a retrospective study Spiegel et al. evaluated a composite of life‐threatening arrhythmia, inpatient STEMI, cardiac or respiratory arrest, or death in intermediate HEART score patients admitted to the hospital after a negative ED evaluation 25 . This study showed a low cardiovascular risk for inpatient intermediate‐risk HEART score if there was a non‐ischemic ECG.…”

Section: Discussionmentioning

confidence: 99%

Early emergency department discharge for intermediate heart score patients presenting for chest pain

Pawlikowski,

Hubbard,

Krauss

et al. 2023

JACEP Open

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Study ObjectiveThe use of the HEART score to risk stratify patients for short‐term major adverse cardiac events in the emergency department (ED) setting is well established. Although discharge to home for low‐risk HEART score patients is widely accepted as safe practice, there are limited outcomes data on moderate‐risk HEART score patients discharged to home. We investigated the safety of discharging moderate‐risk HEART score patients to home from the ED with established early cardiology follow‐up.MethodsWe performed a retrospective cohort analysis of patients presenting to the ED with chest pain from April 2020 through December 2020. Patients were evaluated in the ED and underwent serial conventional troponin testing and electrocardiogram (ECG). Clinicians calculated a HEART score and employed shared decision‐making with moderate‐risk patients (score 4–6), offering hospital admission versus discharge home with a formalized process for rapid cardiology follow‐up (within 2 business days). We assessed the frequency of acute myocardial infarction or death at 30 days and before cardiology follow‐up.ResultsDuring our study period, 2939 patient encounters were screened for chest pain. Of these, 333 of 547 eligible moderate‐risk HEART score patients were referred for rapid follow‐up. The median time to follow‐up appointment was 2.9 business days (interquartile range 1.3, 6.5), and 264 (79%) of patients kept their follow‐up appointment. One patient (0.3%) suffered death within 30 days, before cardiology follow‐up. There were no myocardial infarctions.ConclusionsThese results suggest that moderate‐risk HEART score patients may be considered for discharge from the ED with rapid cardiology follow‐up. Formalizing processes to facilitate these early evaluations may represent a viable alternative to hospital admission, without diminishing patient outcomes.

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“…The HEART score is a nonspecific scoring system that does not require inclusion or exclusion criteria for patients with chest pain, and the items of the score are easy to collect data and less difficult to calculate, which facilitates daily use by clinical workers [ 16 ]. Unlike other chest pain scoring systems, the HEART score includes patient history, ECG, age, risk factors, and troponin levels, emphasizing the combination of ECG and troponin levels, which is more accurate than conventional assessment methods [ 17 ].…”

Section: Discussionmentioning

confidence: 99%

Predictive Value of the HEART Score Combined with Hypersensitive C-Reactive Protein for 30 d Adverse Cardiovascular Events in Patients with Acute Chest Pain

Lin

Zhang

Tang

et al. 2022

Emergency Medicine International

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Purpose. This study aimed to explore the predictive value of the HEART score combined with hypersensitive C-reactive protein (hs-CRP) for 30 d major adverse cardiovascular events (MACEs) in patients with acute chest pain. Methods. 103 patients with acute chest pain admitted to the emergency department of our hospital from May 2020 to May 2022 were selected as the study subjects. The patients’ HEART score and plasma hs-CRP level were recorded. The patients were followed up for 30 d to observe whether MACE occurred. Results. Among 103 patients with acute chest pain, MACE occurred in 8 cases within 30 d of follow-up, and the probability of MACE was 7.76%. There was a statistically significant difference in 30 d MACE risk among patients with different HEART score stratification ( P < 0.05 ). The age, HEART score, and hs-CRP levels of patients in the MACE group were higher than those in the non-MACE group ( P < 0.05 ). The HEART score and the hs-CRP level were independent risk factors for 30 d MACE in patients with acute chest pain ( P < 0.05 ). The AUC of the HEART score combined with hs-CRP in the occurrence of 30 d MACE in patients with acute chest pain was 0.901, which was significantly higher than 0.720 and 0.758 of single detection. Conclusion. The HEART score combined with hs-CRP can better predict the occurrence of 30 d MACE in patients with acute chest pain.

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Clinically relevant adverse cardiovascular events in intermediate heart score patients admitted to the hospital following a negative emergency department evaluation

Cited by 10 publications

References 27 publications

Multicenter analysis to assess risk of major adverse cardiac events in patients undergoing high‐sensitivity troponin testing in the emergency department

Multicenter analysis to assess risk of major adverse cardiac events in patients undergoing high‐sensitivity troponin testing in the emergency department

Early emergency department discharge for intermediate heart score patients presenting for chest pain

Predictive Value of the HEART Score Combined with Hypersensitive C-Reactive Protein for 30 d Adverse Cardiovascular Events in Patients with Acute Chest Pain

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