HEART Score in the ED

Morning Report 1/8/16

HEART score in the ED. Presented by Dr. Kopping. Edited by Dr. deSouza.

-Chest pain: Cause for more than 8k…no, 80k…no, 8 MILLION visits!!

-What this is about?

-Not the 60 year-old sweaty guy with crushing chest pain, STE, and trop of 4000 (How many of those do you see?)

-Not the 18 year-old girl elbowed in the chest, now with a bruise, and extremely tender

-It’s the 52 year-old with PMH of HTN c/o intermittent chest pain; ECG with V5/6 T inversion…Lots of variability in practice styles and this is the grand majority of ED chest pain patients

-Along comes the HEART score

-0 to 10 based on 5 criteria: History, Age, ECG, risk factors, troponin

Why I like:

-Applies to ALL chest pain ED patients

-Easy to use

-My job is to find ACS; HEART performs better than previous scoring systems at identifying ACS

-Alternative scoring systems such as TIMI predict complications of people who have “confirmed” ACS

Limitations:

-Study population- Netherlands is not the hot new neighborhood in Brooklyn

-Still requires a troponin level

HEART score and risk of major adverse cardiac events (MACE) at 6 weeks:

0-3: 0.9%   

4-6: 12 %

>/=7: 65%

Something that can be used but still needs some investigation in broad populations.

Editor’s note:

There is a University of Maryland chest pain protocol that was designed by a committee of MDs AND suits (risk managers and CMOs). It involves the use of a decision-making aid for patients for the purpose of shared decision-making. See link below.

http://epmonthly.com/article/beyond-heart-building-a-better-chest-pain-protocol/

References:

1. Bachus et al. “Risk Scores for Patients with Chest Pain: Evaluation in the Emergency Department” Current Cardiology Reviews, 2011;(7):2-8

2. http://www.emdocs.net/heart-matter/

3. Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Netherlands Heart Journal. 2008;16(6):191-6.

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Brian

Kings County Hospital | SUNY Downstate Emergency Medicine Resident -Clinical Monster Webmaster

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1 comment for “HEART Score in the ED

  1. iandesouza
    January 17, 2016 at 11:25 pm

    One more recent reference:

    The HEART Pathway Randomized Trial Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge. Circ Cardiovasc Qual Outcomes. 2015;8:195-203.
    DOI: 10.1161/CIRCOUTCOMES.114.001384.

    Background—The HEART Pathway is a decision aid designed to identify emergency department patients with acute chest pain for early discharge. No randomized trials have compared the HEART Pathway with usual care.

    Methods and Results—Adult emergency department patients with symptoms related to acute coronary syndrome without ST-elevation on ECG (n=282) were randomized to the HEART Pathway or usual care. In the HEART Pathway arm,
    emergency department providers used the HEART score, a validated decision aid, and troponin measures at 0 and 3 hours to identify patients for early discharge. Usual care was based on American College of Cardiology/American Heart
    Association guidelines. The primary outcome, objective cardiac testing (stress testing or angiography), and secondary outcomes, index length of stay, early discharge, and major adverse cardiac events (death, myocardial infarction, or
    coronary revascularization), were assessed at 30 days by phone interview and record review.

    Participants had a mean age of 53 years, 16% had previous myocardial infarction, and 6% (95% confidence interval, 3.6%–9.5%) had major adverse cardiac events within 30 days of randomization. Compared with usual care, use of the HEART Pathway decreased objective cardiac testing at 30 days by 12.1% (68.8% versus 56.7%; P=0.048) and length of stay by 12 hours (9.9 versus 21.9 hours; P=0.013) and increased early discharges by 21.3% (39.7% versus 18.4%; P<0.001). No patients identified for early discharge had major adverse cardiac events within 30 days.

    Conclusions—The HEART Pathway reduces objective cardiac testing during 30 days, shortens length of stay, and increases
    early discharges. These important efficiency gains occurred without any patients identified for early discharge suffering
    MACE at 30 days.

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