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

Abstract

Chest pain is one of the most common presentations to the emergency department (ED) and HEART score (history, ECG, age, risk factors, and cardiac troponin) is recommended for risk stratification. It has been proposed that the sum of four items with no troponin (HEAR score) below 2 can be used safely to lower testing and reduce length of stay. To assess the performance of the HEAR score in hospital and prehospital settings, we performed a systematic review and meta-analysis. English studies on the performance of the HEAR score in patients with acute chest pain were included. They were excluded if data are inaccessible. MEDLINE, Embase, Evidence-Based Medicine Reviews, Scopus, and web of science were searched from 1946 to July 2021. The quality of studies was assessed using Quality Assessment of Diagnostic Accuracy Studies version 2. Acute coronary syndrome or major adverse cardiac events prediction were outcomes of interest. The performance indices with 95% confidence intervals (CIs) were extracted. Inverse variance and the random-effects model were used to report the results. Of the 692 articles on the HEAR score, 10 studies were included in the analysis with 33 843 patients. Studies were at low to moderate risk of bias. Three studies were in prehospital and three were retrospective. The pooling of data on the HEAR score showed that the sensitivity at the HEAR<2, <3, and <4 cutoffs in the ED were 99.03% (95% CI, 98.29–99.77), 97.54% (95% CI, 94.50–100), and 91.80% (95% CI, 84.62–98.98), respectively. The negative predictive values (NPVs) for the above cutoffs were 99.84% (95% CI, 99.72–99.95), 99.75% (95% CI, 99.65–99.85), and 99.57% (95% CI, 99.11–100), respectively. Of note, for the HEAR<2, negative likelihood ratio was 0.07 (95% CI, 0.02–0.12). In the prehospital, at the HEAR<4 cutoff, the pooled sensitivity and NPV were 85.01% (95% CI, 80.56–89.47) and 91.48% (95% CI, 87.10–95.87), respectively. This study showed that in the ED, the HEAR score<2 can be used for an early discharge strategy. Currently, this score cannot be recommended in prehospital setting. Prospero (CRD42021273710).

External validation of the bedside score for the diagnosis of acute cholecystitis

“…Laboratory findings were considered as diagnostic criteria for acute cholecystitis in both Tokyo guidelines (TG07 and TG13), however, these findings have no place in this new scoring system created by Yeh and his colleagues [ 20 ]. Probably the Yeh et al [ 20 ] scoring system helps with a decrease in length of stay in hospital, less medical costs, and fewer adverse effects for the patients presenting to the ED with RUQ pain by using ultrasound and without requiring laboratory testing [ 24 ].…”

“…In 2013, the TG07 was updated to TG13 considering that definitive diagnosis was not possible in TG07 without positive imaging findings characteristic of acute cholecystitis along with local and systemic signs but in TG13, the probable diagnosis could be made without the presence of this criterion [ 21 ]. Moreover, in TG18 same diagnostic criteria as TG13 was suggested without any modification [ 24 ].…”

Efficacy of HEAR and HEART score to rule out major adverse cardiac events in patients presenting to the emergency department with chest pain: study protocol of the eCARE stepped-wedge randomised control trial

“…For this purpose, we previously described the HEAR score (History, ECG, Age, Risk factors), a partial history, ECG, age, risk factors, troponin (HEART) score. 8 9 In observational studies, the HEAR score exhibited good performances with a very low rate of failure [8][9][10] (figure 1). A patient with a HEAR score below 2 is considered low risk, allowing to rule out an AMI without troponin measurements.…”

“…Patients are included in the study if presenting to a participating ED for non-traumatic chest pain, are over the age of 17 years, have expressed their oral (France) or written (Belgium) consent to participate and have up-to-date health insurance coverage. Criteria for non-inclusion are as follows: (1) 30-day follow-up is not possible; (2) ST-segment elevation myocardial infarction on the ECG at admission; (3) chest pain formally related to another diagnosis other than an ACS before inclusion (ie, pneumothorax, pneumonia, etc); (4) patients having had a troponin test in the last 24 hours; (5) patients referred from other healthcare structure, other than primary care; (6) patients already included in this study and still in their follow-up period; (7) pregnant, breast feeding or parturient patients; (8) patients deprived of liberty by judicial or administrative procedures; (9) patients undergoing forced psychiatric care; (10) patients under legal protection measures and (11) patients unable to give free and informed consent. Patients are excluded from the main analysis if (1) follow-up is impossible or (2) if a component of the HEAR or HEART score is missing, and its potential values may change the risk category of the patient.…”

Contemporary approaches to Pulmonary Embolism Diagnosis – a clinical review

“…As it is the case for early exclusion of acute coronary syndrome suspicion, a clinical decision rule can also identify patients with a very low probability of PE in whom PE can be safely excluded without the need for further investigation. [40] The Pulmonary Embolism Rule-out Criteria (PERC) include age of 50 years or greater, heart rate over 100 beats per minute, pulse oximetry below 95%, unilateral leg swelling, hemoptysis, recent surgery or trauma, prior PE or DVT, and hormone use. (Table 1) [28,41] The absence of all of these criteria allows to safely rule out PE, without the need of further testing.…”