Sex‐Based Differences in the Performance of the HEART Score in Patients Presenting to the Emergency Department With Acute Chest Pain

Abstract

BackgroundSex‐based differences in clinical presentation, pathophysiology, and outcomes of patients with acute chest pain are increasingly being recognized, but are not implemented in guidelines and clinical prediction tools. We evaluated the performance of the HEART score in women versus men, because sex‐based differences may exist among the algorithm's components: history, electrocardiogram, age, risk factors, and admission troponin level.Methods and ResultsThe HEART score was retrospectively assessed in 831 women and 1084 men presenting to the emergency department with acute chest pain, assigning patients to the low‐, intermediate‐, or high‐risk category for the occurrence of major adverse cardiac events (MACE) within 6 weeks. MACE, consisting of myocardial infarction, coronary revascularization, and all‐cause death, also included events during index visit. Six‐week MACE rates were 2 times lower in women than men (10.0% versus 20.8%; P<0.01). Despite similar discriminatory accuracy of the HEART score among women and men (c‐statistic, 0.80 [0.75–0.84] versus 0.77 [0.74–0.81]; P=0.43), 6‐week MACE rates were significantly lower in women than men across all HEART risk categories: 2.1% versus 6.5% (P<0.01) in the low‐risk category, 12.7% versus 21.3% (P<0.01) in intermediate‐risk category, and 53.1% versus 77.0% (P=0.02) in the high‐risk category. The HEART score‐adjusted risk ratio for men was 1.6 (1.3–2.0; P<0.01).ConclusionsThe markedly higher 6‐week MACE risk in men across all HEART risk categories should be taken into account when using the HEART score to guide clinical decision making; early discharge with a low‐risk HEART score appears less safe for men than women with acute chest pain.

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).…”

“…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) …”

Extracellular Vesicle cystatin c is associated with unstable angina in troponin negative patients with acute chest pain

“…This study is an exploratory sub analysis of the prospectively collected data from the MINERVA study. Study details are described in detail previously [ 18 ]. Shortly, consecutive patients >18 years presenting with acute chest pain at the emergency room (ER) were included.…”

Sex as a Biological Variable in Emergency Medicine Research and Clinical Practice: A Brief Narrative Review

“…In the few studies that did evaluate these scores by sex, differential performance was seen despite similar discriminatory and calibration characteristics 47 of the scores. 48 Men were noted to have worse outcomes, suggesting that early discharge for low-risk men by HEART or TIMI scores may be less safe for men as compared to women with acute chest pain. This is likely due to the higher rates of major adverse outcomes (MACE) seen in men as compared to women with AMI, highlighting the need for sex-specific risk stratification scores.…”