Backus BE, Six AJ, Kelder JC et al. “A prospective validation of the HEART score for chest pain patients at the emergency department” International Journal of Cardiology 168(2013): 2153-2158
Chest pain is a common presenting complaint in the Emergency Department and risk stratification is important for determining which patients are safe to discharge and which require admission for observation or further workup. The authors of this study state their intent was to create a simple scoring system that would be clinically relevant with a strong ability to predict adverse cardiac outcomes in chest pain patients.
The HEART score was created by the authors of the study specifically to risk stratify chest pain patients in the Emergency Department. The HEART score gives 0-10 points based on History, ECG, Age, Risk factors, and a single Troponin.
This was a prospective study across 10 different hospitals in the Netherlands over the course of a year. Patients who presented with chest pain were eligible, and 2,388 patients were ultimately enrolled. Physicians completed a Case Report Form with relevant patient information from history/exam, troponin results and ECGs were included as well. ECGs were blindly read by cardiologists not involved in the patients care and the HEART score was then calculated for each study subject.
Primary endpoint was Major Adverse Cardiac Event within 6 weeks of presentation to the ED. A MACE was defined as AMI, PCI, CABG, coronary angiography revealing procedurally correctable stenosis, and all cause mortality. Secondary endpoints were 6 week occurrence of AMI and death, ACS within 3 months, or coronary angiography within 3 months.
2,388 subjects were enrolled in the study. 17% (407 subjects) had a MACE within 6 weeks. The breakdown of MACE were 155 subjects with AMI, 251 with PCI, 67 with CABG, 44 with conservative therapy, and 16 deaths.
Investigators found that only 1.7% of subjects with low HEART score (0-3 points) had a MACE, 16.6% of subjects with moderate score (4-6 points), while subjects with a high HEART score (7-10 points) had 50.1% occurrence of MACE.
The HEART score was found to have a high predictive value when compared with the GRACE and TIMI scores – overall c statistics for HEART score were 0.83, 0.75 for TIMI, and 0.70 for GRACE. The authors also found that the HEART score remained predictive in diabetics, females, and the elderly.
The HEART score can be a useful method to risk stratify patients in the Emergency Department who present with chest pain. In particular, patients with a low HEART score have a >98% likelihood that they will not have a MACE in the next 6 weeks.