Managing chest pain in the emergency room remains a complex and resource-intensive endeavor. Of patients presenting to the emergency room with chest pain, only about 20% turn out to be having an acute coronary syndrome, while roughly two-thirds get admitted for further evaluation and risk stratification.
These admissions often are unnecessary and they significantly add to the economic burden on our healthcare system. Further, the risk for false-positive work-ups is elevated in such scenarios and can result in unnecessary invasive testing. To complicate matters, upwards of 6% of acute coronary syndromes are being missed, adding to physician anxiety when managing patients with chest pain and further promoting more defensive practices. The HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score is a short-term risk-stratification tool that could be used to safely risk stratify patients who are at low risk for having a major adverse cardiovascular event (MACE) over the next six weeks.1
The score is comprised of a number from 0-2 that is assigned for each of the five factors. Total scores range from 0 to 10. For example, if a patient has zero risk factors for atherosclerotic heart disease, then he/she would get a score of 0 for the risk factors category. If the patient has more than 3 risk factors, or a history of established atherosclerosis, his/her risk factor score would be 2.
The scores of each individual criterion are then added together. Patients with a total score of 3 or less are considered low risk … those with a score of 4 to 6 are considered intermediate risk … and those with a score of 7 or greater are considered high risk and most likely to benefit from an early invasive strategy.2
Poldervaart, et al recently explored whether the HEART score could be used to safely risk stratify emergency department patients who were at sufficiently low risk for discharge. Although research into this area has been done previously, Poldervaart and his colleagues went further to investigate whether using the HEART score reduced hospital costs, utilization, and, ultimately, admissions.
The study was a randomized trial with an interesting design. It involved 9 emergency departments in the Netherlands. All of them started with standard of care — whatever they were doing before the trial started was continued upon initiation of the trial. Then every 6 weeks, a different hospital was randomly selected to switch over to using the HEART score to stratify their patients, until eventually all 9 hospitals were using the HEART score.
Patients who were at low cardiovascular risk (they had a HEART score of 3 or less) were discharged from the ED with outpatient follow-up.
Those at intermediate risk (a HEART score of 4-6) were hospitalized for observation and further evaluation, including testing for cardiac enzymes, having an ECG, or even having an inpatient stress test. Those at the highest risk (a HEART score above 7) were referred for prompt early invasive treatment.
Emergency department physicians could deviate from the algorithm if they felt that it was necessary. However, those physicians who did deviate often didn’t provide reasons for choosing an alternative treatment paradigm. All patients, regardless of treatment strategy, were then monitored for adverse cardiovascular events over the following 6 weeks and again at 3 months. The investigators then used the collected data to determine costs and resource utilization for each patient.2
Overall, there were 3666 patients included in the study, but 3 withdrew and 15 were lost to follow-up. Of the remaining 3648 patients, the mean age was 62 years. Thirty-nine percent were calculated to have a HEART score of less than 3, 47% had a score between 4 and 6, and 11% had a score greater than 7.
Using the HEART score to stratify care resulted in a non-inferior (albeit lower) incidence of MACE — 18.9% compared to 22.2% incidence for patients who underwent usual care. While these findings are not completely novel, they add to the growing body of evidence that shows that using a risk-assessment score to risk stratify patients and guide therapy is a reasonable and safe approach.2