External validation of a low HEAR score to identify emergency department chest pain patients at very low risk of major adverse cardiac events without troponin testing

Abstract

Background The history, ECG, age, risk factor (HEAR) score has been proposed to identify patients at sufficiently low risk of acute coronary syndrome that they may not require troponin testing. The objective of this study was to externally validate a low HEAR score to identify emergency department (ED) patients with chest pain at very low risk of 30-day major adverse cardiac events (MACE). Methods This was a secondary analysis of a prospective cohort of patients requiring troponin testing to rule out myocardial infarction (MI) in a large urban ED. HEAR scores were calculated in two cohorts: (1) patients with no known history of coronary artery disease (CAD); and (2) all eligible patients. The proportion of patients classified as very low risk, sensitivity, specificity, predictive values and likelihood ratios at each cut-off were quantified for index acute myocardial infarction (AMI) and 30-day MACE at HEAR = 0 and HEAR ≤ 1 thresholds. Results Of the 1150 patients included in this study, 820 (71.3%) had no history of CAD, 97 (8.4%) had index AMI and 123 (10.7%) had 30-day MACE. In patients with no prior history of CAD, HEAR ≤ 1 identified 202 (24.6%) of patients as very low risk for 30-day MACE with 98.4% (95% CI 91.6-99.9%) sensitivity. Among all patients, HEAR ≤ 1 identified 202 (17.6%) patients as very low risk for 30-day MACE with 99.2% (95% CI 95.6-99.9%) sensitivity. Conclusions A HEAR score ≤ 1 can identify more than 17% of all patients as very low risk for index AMI and 30-day MACE and unlikely to benefit from troponin testing. Broad implementation of this strategy could lead to significant resource savings. Keywords HEAR score • Chest pain • Risk stratification RésuméContexte Le score HEAR (History, ECG, Age, Risk Factor) a été proposé pour identifier les patients présentant un risque suffisamment faible de syndrome coronarien aigu pour ne pas nécessiter de test à la troponine. L'objectif de cette étude était de valider à l'externe un faible score HEAR afin d'identifier les patients du service d'urgence (DE) souffrant de douleurs thoraciques à très faible risque d'événements cardiaques indésirables majeurs (MACE) de 30 jours. Méthodes Il s'agissait d'une analyse secondaire d'une cohorte prospective de patients nécessitant un test à la troponine pour exclure un infarctus du myocarde (IM) dans un grand service d'urgence urbain. Les scores HEAR ont été calculés dans deux cohortes : (1) les patients sans antécédents connus de maladie coronarienne (MC) ; et (2) tous les patients éligibles. La proportion de patients classés à très faible risque, la sensibilité, la spécificité, les valeurs prédictives et les rapports de vraisemblance à chaque seuil ont été quantifiés pour l'infarctus aigu du myocarde (IAM) de l'index et la MACE à 30 jours aux seuils HEAR = 0 et HEAR ≤ 1.

The performance of HEAR score for identification of low-risk chest pain: a systematic review and meta-analysis

“…We tried to communicate with the corresponding authors of the abstracts via email for their published studies in full text, but received only studies that were already included. Therefore, 10 studies were finally included and considered eligible for systematic review and analysis [9,10,33–40] (Supplementary Figure 1, Supplemental digital content 2, http://links.lww.com/EJEM/A332 ).…”

“…In this systematic review, 33 843 patients were included from 10 studies [9,10,33–40]. Five studies were conducted in Europe [9,33,34,38,40], one in Asia [37], and the rest in North America [10,35,36,39].…”

“…In this systematic review, 33 843 patients were included from 10 studies [9,10,33–40]. Five studies were conducted in Europe [9,33,34,38,40], one in Asia [37], and the rest in North America [10,35,36,39]. Seven studies were conducted in the EDs [9,10,34–38] and three studies were in the prehospital [33,39,40].…”

“…Therefore, 10 studies were finally included and considered eligible for systematic review and analysis [9,10,33-40] (Supplementary Figure 1, In this systematic review, 33 843 patients were included from 10 studies [9,10,[33][34][35][36][37][38][39][40]. Five studies were conducted in Europe [9,33,34,38,40], one in Asia [37], and the rest in North America [10,35,36,39]. Seven studies were conducted in the EDs [9,10,[34][35][36][37][38] and three studies were in the prehospital [33,39,40].…”

Journal update monthly top five

“…However, questions remain, including the additional value of risk scores over high-sensitivity troponin testing alone 1. In this secondary analysis of 1150 prospectively recruited patients, O’Reilly et al sought to externally validate the HEAR score (HEART score minus troponin) and estimate the proportion of patients who could be safely discharged from the ED without any troponin assay 2. They found that a HEAR score of ≤1 identified 17.6% of patients as very low risk for any major adverse cardiac event (MACE) up to 30 days, with a sensitivity of 99.2% (95% CI 95.6% to 99.9%).…”