Using HEART2 score to risk stratify chest pain patients in the Emergency Department: an observational study

Abstract

Background A significant number of chest pain patients had previous cardiac imaging tests (CIT) performed before being presented to the Emergency Department (ED). The HEART (history, electrocardiogram, age, risk factors, and troponin) score has been used to risk-stratify chest pain patients in the ED, but not particularly for patients with CIT performed. We aim to modify the current HEART score with the addition of most recent CIT findings (referred to as HEART2 score), to predict a 30-day major adverse cardiac event (MACE) among ED chest pain patients, compare the performance accuracy of using HEART versus HEART2 score for 30-day MACE outcome predictions, and further determine the value of HEART2 in a subset group of ED chest pain patients (i.e., ones with previous CIT). Methods This is a single-center observational study. We included chest pain patients with HEART scores calculated during their index ED visits. A modified HEART2 score was developed with the addition of CIT findings as one of the HEART2 components. Patients were divided into three groups, including low (≤ 3), moderate (4–6), and high-risk HEART/HEART2 scores (≥ 7). MACE occurrence of a patient with different risks of HEART and HEART2 scores and overall performance accuracy of HEART versus HEART2 score predicting MACE outcomes were compared. Results We included a total of 9419 chest pain patients at ED, among which one out of five patients (1874/9419) had previous CIT performed. Fewer (38.2%) of such patients had low-risk HEART scores in comparison to 55.5% of low-risk HEART2 scores (p < 0.001). The MACE outcomes were similar in low-risk HEART patients compared with low-risk HEART2 patients (2.2% versus 3.1%, p = 0.3021). The overall performance accuracy of using the HEART2 score to stratify chest pain patients with previous CIT was better than using the HEART score’s (AUC 0.74 versus 0.71, p = 0.0082). Conclusions Using the HEART2 score might be suitable to stratify low-to-moderate risk chest pain patients at ED with a similar 30-days MACE occurrence compared to the HEART score. More importantly, with the use of similar low-risk criteria (HEART2 ≤ 3), over 45% more chest pain patients with previous CIT performed could be discharged directly from ED.

A Closer Look at the HEART Score

“…To improve upon the discriminatory power of the original HEART score or to circumvent some of its limitations, a number of variants of the HEART score have been reported over the years. Table 2 [7,10,[14][15][16][17][18][19][20] summarizes the variants described here; HEAR score, modified HEART score, HEART pathway, HEART-2 score, and HEARTS 3 score.…”

“…Lastly, Schrader et al seek to improve the original HEART score in the patient population with recurrent chest pain that have done prior cardiac imaging tests (CITs) [ 20 ]. However, they desired that the modified score would still retain its accuracy of risk stratifying ED patients in the absence of CIT.…”

A streamlined Emergency Department approach to moderate risk chest pain in patients with no pre‐existing coronary artery disease: A pilot study

“…NHFA/CSANZ guidelines recommend that further diagnostic imaging be performed on moderate risk patients to provide prognostic information, and that this testing be done during or shortly after discharge from ED 6 with no specific timing suggested. This moderate risk group is, however, a heterogenous group of patients with a risk of MACE somewhere between 2% and 8%, 8–10 10%–20% of whom will already have had previous cardiac imaging, 9 and trying to further delineate risk among the subgroups within this cohort is complex. As such, various management strategies are employed in this group and many of these patients are admitted from the ED for short stay inpatient management, including changes in medical therapy or functional testing.…”