February’s Food & Journal Club (FJC) article was chosen by one of the senior residents to open up a discussion regarding evaluation of chest pain in the ED and the utility of the HEART score in our patient population. The gracious Dr. Stetz hosted, the venerable Dr. Wiener presided, and we enjoyed delicious dumplings from Oh! Dumplings.
After gorging ourselves on cucumber salad, noodles, and dumplings on dumplings, we settled in to the comfy couch to talk about the approach to patients with chest pain.
Quick summary: Researchers used ED visits in the Kaiser Permanente Southern California system to reassess patient’s 30-day risk of MI or death based on their HEART score. They looked at 29,196 ED visits with an overall incidence of 0.6% for their primary outcome. In order to evaluate if the HEART score was a good predictor, they used the C-statistic – this measures the probability a randomly selected patient who experienced an event had a higher risk score than a patient who had not experienced the event. The investigators found that it was a good-to-strong model. They concluded that HEART score ≤ 5 could be used in their population to support an outpatient work-up for the patient’s chest pain.
The graph and chart below are the visual depictions of the meat of the paper, for those of us who benefit from something other than words. It is a pretty impressive trend of increasing risk with increasing HEART score. It also allows the reader to look at the risk and determine at which threshold they may be comfortable discharging the patient. They present the data by individual score as well as the three levels (high, intermediate, low) previously established (below the graph).
The group was overwhelmingly junior residents who held their own in providing new insights and points of discussion including how they have individually used the HEART score to strengthen their disposition decision in the ED.
Major discussion points from FJC:
- The goal of the article appears to be to avoid unnecessary admissions
- Results demonstrate that in the study population, the threshold for discharge for “low risk” patients could be raised to 5
- How applicable is this to our patient population given:
- The incidence of 30 day events in this study was very low (0.6%)
- The demographics of this population may be inconsistent with the Kings County patient population
- The system in which you work affects how you can use the HEART score – demographics/incidence of disease, good primary care follow-up vs. prompt cardiology referral, inpatient vs. observation
After dinner and discussion, we moved on to the ice cream course, complete with some spicy chocolates.
Bottom line: Read the original HEART score (PMID:25737484) and recent validation study (PMID:23892941) and check out the EM:RAP on this topic (https://www.emrap.org/episode/thecollector/originofthe) to get a real grasp on the origins of this data. Use the HEART score to strengthen your clinical decision-making, and in certain patient populations, consider raising your HEART score threshold for discharge of a patient with good follow-up.
T3
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