The challenge in the ED is to not only to identify high risk patients but also to identify patients who can be safely discharged home. Specifically, when dealing with ACS, dynamic ECG changes or positive cardiac biomarkers is pretty much a slam dunk admission in most cases, but a lack of these does not completely rule out ACS. Currently, most guidelines and risk stratification scores focus on the identification of high risk ACS patients that would benefit from early aggressive therapies, but what about all the other chest pain patients that don’t have ACS… are they accounted for?
WHAT ARE SOME OF THE SCORING METHODS CURRENTLY USED?
PURSUIT: Does not include troponin assays as part of score and the majority of the score is dependent on patient age.WHAT IS THE APPLICABILITY OF EACH SCORE TO CLINICAL PRACTICE IN THE ED?
TIMI: Simple to use, but has a poor predictive power (i.e. c-statistic 0.65)
GRACE: Very complex to use and a large portion of the score is dependent on the patient age. Also patients not divided into different risk groups
FRISC: Like TIMI, is simple to use but has a poor predictive power (i.e. c-statistic 0.70)
All of the above scores are well validated, but none of them emphasizes patient history as part of the score, used in identification of ACS in the ED setting, and chest pain due to causes other than ACS were not evaluated in these trials. In truth, clinical judgement plays a huge role for physicians in the ED when evaluating chest pain patients, so wouldn’t it make sense to have a risk score that follows this? Well, that is exactly what the HEART score does!
WHAT IS THE HEART SCORE (ORIGINAL STUDY)?
HAS THE HEART SCORE BEEN VALIDATED AGAINST TIMI AND GRACE SCORES (VALIDATION STUDY)?
What they did:
2,440 unselected, chest pain patients from 10 hospitals
Applied TIMI, GRACE, and HEART Scores
Primary endpoint:
Occurrence of major adverse cardiac events (MACE) at 6 weeks
MACE = AMI, PCI, CABG, and death.
Results of validation study (Different than original study shown above):
Low HEART Score (0 -3) = 1.7% MACE Rate
Intermediate HEART Score (4 – 6) = 16.6% MACE Rate
High HEART Score (7 – 10) = 50.1% MACE Rate
C-statistic of HEART Score (0.83) > TIMI (0.75) > GRACE (0.70)
Limitations:
Study performed on patient population from the Netherlands
Observational study
Each ED had different cut-off values for positive troponins. 45 patients lost to follow up
No comparison of Heart Score to clinical gestalt.
Confidence interval was a bit wide when looking at the total study population (i.e. 2.2)
Conclusion: The HEART score provides a quick and reliable predictor of outcomes in chest pain patients presenting to the ED.
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