Improving Risk Stratification of Patients With Chest Pain in the Emergency Department

Abstract

Objective: The HEARTS3 score is used to predict acute coronary syndrome by evaluating the findings of chest pain patients at the end of the second hour. Additionally, the American College of Cardiology (ACC)/American Heart Association (AHA) 2014 non-ST elevation acute coronary syndrome (NSTE-ACS) management guideline suggests assessing cardiac troponin levels at the third and sixth hours as a class 1A recommendation. This study aimed to explore the value of the HEARTS3 score for the evaluation of patients with chest pain and its utility for determining whether a patient is eligible for early discharge from the emergency department.Material and methods: This study was prospectively conducted between March 1, 2016 to May 31, 2016 at the ED of the Research and Training Hospital in İstanbul. A total of 136 patients were evaluated, and HEARTS3 scores were calculated at the second, third, and sixth hours. Receiver operating characteristic (ROC) curves were used to calculate the specificity, sensitivity, negative predictive value (NPV) and positive predictive value (PPV) of these scores. The primary outcome was the occurrence of major adverse cardiac events (MACEs) within 30 days.Results: In total, 29 patients with MACEs and 107 patients without MACEs were identified within 30 days. Based on the ROC curve, the cutoff value for early discharge was 6. The area under curve (AUC) values were 0.943, 0.963 and 0.976 at the second, third, and sixth hours, respectively. The sensitivity of the second-hour HEARTS3 score was 96.6%, and the NPV was 98.6%. Both the sensitivity and NPV reached 100% at the sixth hour. Conclusion:The HEARTS3 score was considered a feasible method for the prediction of MACEs. We concluded that a patient with a HEARTS3 score less than 6 may be discharged without serial troponin and ECG examination.

Measurement of Cardiac-Specific Biomarkers in the Emergency Department: New Insight in Risk Evaluation

“…In order to balance the risk between a hasty discharge versus the potential harms caused by a cardiac assessment in patients admitted to the ED with suspected acute cardiovascular disease, the recent expert documents and guidelines recommend the measurement of specific cardiac biomarkers (NPs and hs-cTn) for the early identification of the presence of myocardial dysfunction and/or injury and to significantly reduce the duration and costs of hospitalization [8,10,[14][15][16][17][18][19][20]56,76,77,98,100,101]. Moreover, specific cardiac biomarkers (especially hs-cTnI and hs-cTnT) are useful predictors of mortality and MACE in patients admitted to the ED with suspected acute cardiovascular disease [17,19,22,53,84,[102][103][104].…”

“…In patients admitted to the ED with suspected ACS, including those with AHF, the measurement of hs-cTnI and hs-cTnT should be considered the first-line biomarkers, in order to identify the presence of myocardial injury and to quickly rule out ACS, leading to a significant reduction in the duration and costs of hospitalization [14][15][16][17][18][19][20]56,76,77,88,[100][101][102]. Furthermore, several recent clinical studied have demonstrated that hs-cTnI and hs-cTnT are useful predictor biomarkers for mortality and MACE, even in the setting of AHF [17,19,22,53,84,[102][103][104]. In particular, according to the Fourth Universal Definition of Myocardial Infarction [8], an increase in hs-cTnI and hs-cTnT above the 99th percentile URL value proves the presence of myocardial injury in AHF patients.…”

“…Every year, millions of patients are admitted to the EDs of developed countries with clinical symptoms related to acute coronary syndrome (ACS), but the diagnosis of ACS is confirmed in less than 10% of them [10][11][12][13]. In the last years, several documents and international guidelines have been published to suggest some accelerated diagnostic protocols concerning the differential diagnosis of ACS and a more accurate risk stratification of patients admitted to the ED with suspected ACS [14][15][16][17][18][19][20][21][22][23].…”

“…In 2021, Hendley et al [10] properly observed that an ethical dilemma often arises with patients admitted to the ED with thoracic pain, when clinicians try to balance the risk of not diagnosing an ACS with the potential harm caused by a more accurate cardiac work-up [15,17,[20][21][22][23].…”