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, ST-Elevations, 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…Here, there is a large 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 it:
-Applies to ALL chest pain ED patients
-Easy to use
-My job is to find acute coronary syndrome (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:Â 0.9% Â Â
4-6: 12 %
≥ 7: 65%
This is 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 made up of MD, risk managers, and CMOs. It involves the use of a decision aid for patient for the purpose of using shared decision-making when it comes to testing for ACS, See EP Monthly link below.
http://epmonthly.com/article/beyond-heart-building-a-better-chest-pain-protocol/
Read more on Cardiology topics in the ED here.
Presented by Dr. Kopping.
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.
Brian
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1 Comment
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.