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    HEART Score for Major Cardiac Events

    Predicts 6-week risk of major adverse cardiac event.
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    When to Use
    Pearls/Pitfalls
    Why Use

    Any ED patient with chest pain that the physician deems appropriate for an ACS workup.

    The HEART Score is a prospectively studied scoring system to help emergency departments risk-stratify chest pain patients: who will have a MACE within in the next 6 weeks and who will not?

    • It involves only a 1-time troponin, at admission.
    • The rest of the score is based on age, history, risk factors, and EKG.
    • Low risk patients have a score 0-3 and have a less than 2% risk of MACE at 6 weeks.
    • MACE is defined as: all-cause mortality myocardial infarction, or coronary revascularization.
    • All other scores are high risk (risk increasing exponentially) and require further management and admission.
    • While HEART is sometimes compared to TIMI and GRACE (older ACS scores), these measure risk of death for patients with ACS, and do not do as well telling who has ACS in the first place.

    A patient with some nonspecific features of their workup (history, EKG, troponin) can be more objectively risk stratified for their chest pain, quantify their risk, and potentially lead to shorter hospital stays, fewer inappropriate interventions and more appropriate interventions.

    Result:

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    Evidence
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    Critical Actions

    • 0-3: 0.9-1.7% risk of adverse cardiac event. In the HEART Score, these patients were discharged. (0.99% retrospective) (1.7% prospective)
    • 4-6: 12-16.6% risk of adverse cardiac event. In the HEART Score, these patients were admitted to the hospital. (11.6% retrospective) (16.6% prospective)
    • ≥7: 50-65% risk of adverse cardiac event. In the HEART Score, these patients were candidates for early invasive measures. (65.2% retrospective) (50.1% prospective)

    MACE (Major Adverse Cardiac Events) is defined as: all-cause mortality, myocardial infarction, or coronary revascularization.

    Formula

    Addition of the assigned points.

    Facts & Figures

    • Major Adverse Cardiac Event (MACE) was defined in this study as: AMI, PCI, CABG, death.
    • Recently, Ryan Radecki of EM Literature of Note recommended emergency physicians use the HEART Score over the TIMI or GRACE scores for emergency department risk stratification of patients with possibly cardiac complaints.

    Evidence Appraisal

    Was initially developed in a small cohort -- 122 patients with chest pain in an emergency department setting.

    Outcome: MACE at 6 weeks.

    • History was classified by 2 investigators.
    • If information was not specific or not included, the element was tagged as “nonspecific” and 0 points were assigned.
    • If nonspecific and suspcicious items were included in the history, this was deemed “moderately suspicious” and assigned 1 point.
    • EKG:
      • Normal was assigned 0 points.
      • Repolarization abnormalities without ST-depression were assigned 1 point.
      • Abnormalities like bundle branch block, LVH, or repolarization due to digoxin or unchanged repolarization abnormalities also were assigned 1 point.
      • Significant ST depressions or elevations outside other clear causes like bundle branch block or LVH were given 2 points.
    • Risk factors were listed counted by: currently treated diabetes mellitus, current or recent (<one month) smoker, diagnosed hypertension, diagnosed hypercholesterolemia, family history of coronary artery disease, and obesity.
      • If patients had prior history of coronary revascularisation, myocardial infarction, stroke or peripheral arterial disease, they were assigned 2 points for risk factors.
    • If troponin was less than the reference standard, 0 points were assigned. If the troponin level was between 1-2x the reference threshold, 1 point was assigned. Greater than this, 2 points were assigned.
    • Only 2 patients of the 122 were lost to followup; others had an average of 423 days of follow up.
    • 24.1% of patients reached a cardiac endpoint, with two deaths (1.6%), both elderly males with a HEART Score of 8.
    • 1 patient was discharged and 10 days later had an acute myocardial infarction but did well and is alive.


    A much larger validation (Backus 2013) with over 2100 patients had similar -- and likely better -- outcomes numbers.

    Literature

    Validation

    Research PaperBackus BE, Six AJ, Kelder JC, Bosschaert MA, Mast EG, Mosterd A, Veldkamp RF, Wardeh AJ, Tio R, Braam R, Monnink SH, van Tooren R, Mast TP, van den Akker F, Cramer MJ, Poldervaart JM, Hoes AW, Doevendans PA. 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. doi: 10.1016/j.ijcard.2013.01.255. Epub 2013 Mar 7. PubMed PMID: 23465250.Research PaperPoldervaart JM, Reitsma JB, Backus BE, et al. Effect of Using the HEART Score in Patients With Chest Pain in the Emergency Department: A Stepped-Wedge, Cluster Randomized Trial. Ann Intern Med. 2017.Research PaperMahler SA, Riley RF, Hiestand BC, et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes. 2015;8(2):195-203.
    Dr. Barbra Backus

    From the Creator

    From Barbra Backus, MD, PhD, co-author of the HEART Score:

    Why did you develop the HEART Score for Major Cardiac Events? Was there a clinical experience that inspired you to create this tool for clinicians?
    The HEART score was created based on expert opinion through examination of many patients with chest pain. The structure of the five elements with a 0, +1, and +2 scoring system (analogous to the Apgar score) helps to translate a long history and examination of a patient with chest pain into a comprehensible score of 0 to 10.
    What pearls, pitfalls and/or tips do you have for users of the HEART Score for Major Cardiac Events? Are there cases in which it has been applied, interpreted, or used inappropriately?
    The great benefit of the HEART score is that it is applicable to all chest pain patients in the ED or ACS unit. A minor pitfall is that the user needs at least some experience taking a chest pain history and reading an ECG to interpret these two elements of the score.
    I had a few questions about definitions — was troponin “on admission” the initial troponin drawn in the ER upon arrival there? Also, how did you define AMI in patients with a troponin already >3x normal? Was it AMI if the troponin continued to trend up, if no obvious EKG changes were seen?
    In all our validation studies, we used the first troponin on arrival. With that single troponin value, the HEART Score has a NPV > 98%. A recent study by Mahler et. al. shows that HEART <3 with 2 sets of negative troponin has a NPV of > 99% for MACE. Of course, every decrease in risk of endpoints is desirable, but HEART with a single troponin is already a very reliable predictor of MACE/ACS.
    For the definition of AMI we used the ESC guidelines. When there was any doubt (i.e., small troponin rise or concurrent arrhythmia) we would send the case to the adjudication committee for a definite risk stratification of the endpoint.
    What recommendations do you have for health care providers once they have applied the HEART Score for Major Cardiac Events? Are there any adjustments or updates you would make to the score given recent changes in medicine?
    The score is relatively new, so there are no major adjustments to make yet. Perhaps after we finish our current studies, we will be able to show that a HEART score with high sensitivity troponin is as good or perhaps better than the original HEART Score.
    I do think that the HEART score is a very good and easy-to-use instrument for every doctor working on an ED or ACS unit. However, the HEART score is just a scoring system and every patient is different. When you have any doubt or uncanny feeling about your patient, follow this: “The HEART Score can never replace our clinical thinking and our gut feeling.”
    Any other comments? Any new research or papers on this topic in the pipeline? Any thoughts on comparisons to other risk scores (GRACE, etc)?
    We are about to finish our implementation study, looking at the benefits, cost-effectiveness and safety of implementing the HEART score to our ED. Within the year, we will also finish studies on the HEART score in conjunction with different sets of troponin, like HEART plus copeptin, FABP and inter-observer variability.
    Finally — any interest or thought about developing your data set into continuous variables in a best-of-fit regression model? We've had a few authors who have taken their point-based scores and turned their variables into continuous ones — allowing us on the site to provide a better outcome estimate for users. (I've also been told these are great for publication, too.)
    We did perform regression analysis on the HEART score. I hope the results will be published soon. I do think that a continuous scoring with corresponding risk could be helpful for many clinicians. For example, helping clinicians to figure out the risk a patient has for potential MACE/ACS with a HEART score of 4 or 6, instead of the groups 0-3, 4-6 and 7-10.

    About the Creator

    Barbra Backus, MD, PhD, worked as a junior cardiologist under Dr. Six prior to her work on the HEART Studies. After completing her PhD, she began a residency in Emergency Medicine at the Albert Schweitzer Hospital in Dordrecht in the Netherlands. Her main research focus is on risk stratification of ACS.

    To view Dr. Barbra Backus's publications, visit PubMed