Article citation: Backus BE, Six AJ, Kelder JC, Bosschaert MA, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013 Oct 3;168(3):2153-8. (Link to the article here)

 

What we already know about the topic: Chest pain is one of the most common complaints in the ED. However, most chest pain patients have no clear cardiac pathology upon initial presentation. Providers are often forced to postpone decision-making while waiting for serial troponins or by admission to observation. This results in prolonged lengths of stay for patients and contributes to ED crowding.

 

Why this study is important: In this study, the authors propose a clinical decision rule (i.e. the HEART score) that can potentially help ED providers decide who can be safely discharged after a single negative troponin.

 

Brief overview of the study: This study is the prospective validation study for the HEART score, which was previously derived in an earlier study by the same authors. This score was designed to be used by ED providers to risk-stratify patients based on history, EKG findings, age, risk factors, and a single troponin. A total of 2,388 patients presenting to one of 10 different EDs with chest pain were included in the study. Only 1.7% of patients with a low HEART score of 0-3 (15/870) had a major adverse cardiac event (MACE) within six weeks. This was less than the predetermined 5% cut-off and so the authors concluded that a low HEART score could safely be used to decide which patients can be discharged early from the ED.

 

Limitations: Primary issues with this study are: (1) The authors used a cut-off of <5% for major adverse cardiac events. In other words, it’s possible that up to 5% (1 in 20) of patients in the “safe for discharge after a single troponin group” could potentially have a MACE. That risk threshold is much too high for most providers. (2) The study was conducted in the Netherlands in 2,388 likely genetically homogenous Caucasian patients. It’s unclear how well the HEART score would hold up in the multicultural diversity of New York City.

 

Take home points: Initially the HEART score was approached with some skepticism by providers due to the limitations noted above. However, multiple subsequent studies have also successfully externally validated its use for identifying patients at low risk of ACS.