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Internal and Emergency Medicine

, Volume 13, Issue 5, pp 727–748 | Cite as

A retrospective external validation study of the HEART score among patients presenting to the emergency department with chest pain

  • Matthew Jay Streitz
  • Joshua James Oliver
  • Jessica Marie Hyams
  • Richard Michael Wood
  • Yevgeniy Mikhaylovich Maksimenko
  • Brit Long
  • Robert Michael Barnwell
  • Michael David April
EM - ORIGINAL

Abstract

Emergency physicians must be able to effectively prognosticate outcomes for patients presenting to the Emergency Department (ED) with chest pain. The HEART score offers a prognostication tool, but external validation studies are limited. We conducted an external retrospective validation study of the HEART score among ED patients presenting to our ED with chest pain from 1 January 2014 to 9 June 2014. We utilized chart review methodology to abstract data from each patient’s electronic medical record. We collected data relevant to each of the five elements of the HEART score: history, electrocardiogram (ECG) interpretation, patient age, patient risk factors, and troponin levels. We calculated the diagnostic accuracy of the HEART score (0–10) for predicting the primary outcome of major adverse cardiac events (MACE) over 6 weeks following the ED visit (coronary revascularization, myocardial infarction, or mortality). We randomly selected 10% of patient charts from which a second investigator abstracted all data to assess inter-rater reliability for all study variables. Of 625 charts reviewed, we abstracted data on 417 (66.7%) consecutive patients meeting study inclusion criteria. Thirty-one (7.4%) of these patients experienced 6-week MACE. We observed no instances of MACE within 6 weeks among subjects with a HEART score of 3 or less. The area under the receiver operator curve (AUROC) is 0.885 (95% confidence interval 0.838–0.931). Patients with a HEART score ≤3 are at low risk for 6-week MACE. Hence, these patients may be candidates for outpatient follow-up instead of inpatient admission for cardiac risk stratification.

Keywords

Chest pain HEART score Low risk Emergency department Acute coronary syndrome 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Funding

None.

Statement of human and animal rights

For this type of study formal consent was not required. This article does not contain any studies with animals performed by any of the authors.

Informed consent

Informed consent was waived at our institution due to the chart review nature of the study.

References

  1. 1.
    Center for Disease Control and Prevention (2013) National Hospital Ambulatory Medical Care Survey: 2013 emergency department summary tables. Center for Disease Control and Prevention, Atlanta, GeorgiaGoogle Scholar
  2. 2.
    Amsterdam EA, Wenger NK, Brindis RG et al (2014) 2014 AHA/ACC Guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 64:e139–e228CrossRefPubMedGoogle Scholar
  3. 3.
    Backus BE, Six AJ, Kelder JC et al (2013) A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol 168:2153–2158CrossRefPubMedGoogle Scholar
  4. 4.
    Amsterdam EA, Kirk JD, Bleumke DA et al (2010) American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Interdisciplinary Council on Quality of Care and Outcomes Research. Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation 122:1756–1776CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Venkatesh AK, Dai Y, Ross JS, Schuur JD, Capp R, Krumholz HM (2015) Variation in US hospital emergency department admission rates by clinical condition. Med Care 53:237–244CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Brooker JA, Hastings JW, Major-Monfried H et al (2015) The association between medicolegal and professional concerns and chest pain admission rates. Acad Emerg Med 22:883–886CrossRefPubMedGoogle Scholar
  7. 7.
    Backus BE, Six AJ, Kelder JC et al (2010) Chest pain in the emergency room: a multicenter validation of the HEART score. Crit Pathw Cardiol 9:164–169CrossRefPubMedGoogle Scholar
  8. 8.
    Backus BE et al (2013) A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol 168(3):2153–2158CrossRefPubMedGoogle Scholar
  9. 9.
    Fesmire FM et al (2012) Improving risk stratification in patients with chest pain: the Erlanger HEARTS3 score. Am J Emerg Med 30(9):1829–1837CrossRefPubMedGoogle Scholar
  10. 10.
    Poldervaart JM et al (2013) The impact of the HEART risk score in the early assessment of patients with acute chest pain: design of a stepped wedge, cluster randomised trial. BMC Cardiovasc Disord 13:77CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Six AJ, Backus BE, Kelder JC (2008) Chest pain in the emergency room: value of the HEART score. Neth Heart J 16(6):191–196CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Mahler SA et al (2015) The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes 8(2):195–203CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Weinstock MB, Weingart S, Orth F, VanFossen D, Kaide C, Anderson J, Newman DH (2015) Risk for clinically relevant adverse cardiac events in patients with chest pain at hospital admission. JAMA Intern Med 175(7):1207–1212CrossRefPubMedGoogle Scholar
  14. 14.
    Mahler SA, Miller CD, Hollander JE et al (2013) Identifying patients for early discharge: performance of decision rules among patients with acute chest pain. Int J Cardiol 168:795–802CrossRefPubMedGoogle Scholar
  15. 15.
    Goldman L, Cook EF, Johnson PA, Brand DA, Rouan GW, Lee TH (1996) Prediction of the need for intensive care in patients who come to the emergency departments with acute chest pain. N Engl J Med 334(23):1498–1504CrossRefPubMedGoogle Scholar
  16. 16.
    Antman EM, Cohen M, Bernink PJ et al (2000) The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA 284:835–842CrossRefPubMedGoogle Scholar
  17. 17.
    Chase M, Robey JL, Zogby KE et al (2006) Prospective validation of the thrombolysis in myocardial infarction risk score in the emergency department chest pain population. Ann Emerg Med 48:252–259CrossRefPubMedGoogle Scholar
  18. 18.
    Fox KA, Dabbous OH, Goldberg RJ et al (2006) Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRAC(E). BMJ 333:1091CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Elbarouni B, Goodman SG, Yan RT et al (2009) Validation of the global registry of acute coronary event (GRAC(E) risk score for in-hospital mortality in patients with acute coronary syndrome in Canada. Am Heart J 158:392–399CrossRefPubMedGoogle Scholar
  20. 20.
    Hess EP, Agarwal D, Chandra S et al (2010) Diagnostic accuracy of the TIMI risk score in patients with chest pain in the emergency department: a meta-analysis. CMAJ 182:1039–1044CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP et al (2007) The strengthening the reporting of observational studies in epidemiology (STROB(E) statement: guidelines for reporting observational studies. Ann Intern Med 147:573–577. doi: 10.7326/0003-4819-147-8-200710160-00010 CrossRefGoogle Scholar
  22. 22.
    Kaji AH, Schriger D, Green S (2014) Looking through the retrospectoscope: reducing bias in emergency medicine chart review studies. Ann Emerg Med 64(3):292–298CrossRefPubMedGoogle Scholar
  23. 23.
    Hess EP, Brison RJ, Perry JJ et al (2012) Development of a clinical prediction rule for 30-day cardiac events in emergency department patients with chest pain and possible acute coronary syndrome. Ann Emerg Med 59:115–1251CrossRefPubMedGoogle Scholar
  24. 24.
    Rationale and design of the GRACE (Global Registry of Acute Coronary Events) (2001) Project: a multinational registry of patients hospitalized with acute coronary syndromes. Am Heart J 141(2):190–199CrossRefGoogle Scholar
  25. 25.
    Boersma E et al (2000) Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. The PURSUIT investigators. Circulation 101(22):2557–2567CrossRefPubMedGoogle Scholar
  26. 26.
    Chase M et al (2006) Prospective validation of the thrombolysis in myocardial infarction risk score in the emergency department chest pain population. Ann Emerg Med 48(3):252–259CrossRefPubMedGoogle Scholar
  27. 27.
    Fleischmann KE et al (2002) Critical pathways for patients with acute chest pain at low risk. J Thromb Thrombolysis 13(2):89–96CrossRefPubMedGoogle Scholar
  28. 28.
    Hess EP et al (2012) The chest pain choice decision aid: a randomized trial. Circ Cardiovasc Qual Outcomes 5(3):251–259CrossRefPubMedGoogle Scholar
  29. 29.
    Lagerqvist B et al (2005) FRISC score for selection of patients for an early invasive treatment strategy in unstable coronary artery disease. Heart 91(8):1047–1052CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Lyon R et al (2007) Chest pain presenting to the emergency department–to stratify risk with GRACE or TIMI? Resuscitation 74(1):90–93CrossRefPubMedGoogle Scholar
  31. 31.
    Than M et al (2011) A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study. Lancet 377(9771):1077–1084CrossRefPubMedGoogle Scholar
  32. 32.
    Pope JH, Aufderheide TP, Ruthazer R, Woolard RH, Feldman JA, Beshansky JR, Selker HP (2000) Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 342(16):1163–1170CrossRefPubMedGoogle Scholar
  33. 33.
    Rusnak RA, Stair TO, Hansen K, Fastow JS (1989) Litigation against the emergency physician: common features in cases of missed myocardial infarction. Ann Emerg Med 18(10):1029–1034CrossRefPubMedGoogle Scholar
  34. 34.
    Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA, Lauer MS (2010) 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular. J Am Coll Cardiol 56(25):e50–e103CrossRefPubMedGoogle Scholar
  35. 35.
    Fesmire FM, Brady WJ, Hahn S, Decker WW, Diercks DB, Ghaemmaghami CA, Jagoda AS (2006) Clinical policy: indications for reperfusion therapy in emergency department patients with suspected acute myocardial infarction. Ann Emerg Med 48(4):358–383CrossRefPubMedGoogle Scholar
  36. 36.
    Forberg JL, Henriksen LS, Edenbrandt L, Ekelund U (2006) Direct hospital costs of chest pain patients attending the emergency department: a retrospective study. BMC Emerg Med 6(1):6CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    McCullough PA, Ayad O, O’Neill WW, Goldstein JA (1998) Costs and outcomes of patients admitted with chest pain and essentially normal electrocardiograms. Clin Cardiol 21(1):22–26CrossRefPubMedGoogle Scholar
  38. 38.
    Wu WK, Yiadom MYA, Collins SP, Self WH, Monahan K (2017) Documentation of HEART score discordance between emergency physician and cardiologist evaluations of ED patients with chest pain. Am J Emerg Med 35(1):132–135CrossRefPubMedGoogle Scholar
  39. 39.
    April MD, Murray BP (2017) Cost effectiveness analysis appraisal and application: an emergency medicine perspective. Acad Emerg Med 24(6):754–768. doi: 10.1111/acem.13186 CrossRefPubMedGoogle Scholar

Copyright information

© SIMI (outside the USA) 2017

Authors and Affiliations

  1. 1.Department of Emergency MedicineSan Antonio Military Medical Center, San Antonio Uniformed Services Health Education ConsortiumSan AntonioUSA
  2. 2.Uniformed Services University of the Health Sciences4301, Jones Bridge RdBethesdaUSA

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