Internal and Emergency Medicine

, Volume 13, Issue 7, pp 1111–1119 | Cite as

Reliability of the CARE rule and the HEART score to rule out an acute coronary syndrome in non-traumatic chest pain patients

  • Thomas MoumnehEmail author
  • Vanessa Richard-Jourjon
  • Emilie Friou
  • Fabrice Prunier
  • Caroline Soulie-Chavignon
  • Jacques Choukroun
  • Betty Mazet-Guilaumé
  • Jérémie Riou
  • Andréa Penaloza
  • Pierre-Marie Roy


In patients consulting in the Emergency Department for chest pain, a HEART score ≤ 3 has been shown to rule out an acute coronary syndrome (ACS) with a low risk of major adverse cardiac event (MACE) occurrence. A negative CARE rule (≤ 1) that stands for the first four elements of the HEART score may have similar rule-out reliability without troponin assay requirement. We aim to prospectively assess the performance of the CARE rule and of the HEART score to predict MACE in a chest pain population. Prospective two-center non-interventional study. Patients admitted to the ED for non-traumatic chest pain were included, and followed-up at 6 weeks. The main study endpoint was the 6-week rate of MACE (myocardial infarction, coronary angioplasty, coronary bypass, and sudden unexplained death). 641 patients were included, of whom 9.5% presented a MACE at 6 weeks. The CARE rule was negative for 31.2% of patients, and none presented a MACE during follow-up [0, 95% confidence interval: (0.0–1.9)]. The HEART score was ≤ 3 for 63.0% of patients, and none presented a MACE during follow-up [0% (0.0–0.9)]. With an incidence below 2% in the negative group, the CARE rule seemed able to safely rule out a MACE without any biological test for one-third of patients with chest pain and the HEART score for another third with a single troponin assay.


Chest pain Major adverse cardiac event Acute coronary syndrome Risk assessment 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Statement of human and animal rights

 The study was approved by the Ethics Committee of the University Hospital Center of Angers on July 18th 2013, and registered N°2013/51. All procedures performed in this study were in accordance with the 1964 Helsinki declaration. This article does not contain any studies with animals performed by any of the authors.

Informed consent

Each patient’s consent was expressly sought and each participant was given a written information on the study. Signed consent forms were not required regarding French current laws on observational studies.


  1. 1.
    Fanaroff AC, Rymer JA, Goldstein SA, Simel DL, Newby LK (2015) Does this patient with chest pain have acute coronary syndrome?: The rational clinical examination systematic review. JAMA 314(18):1955–1965. CrossRefPubMedGoogle Scholar
  2. 2.
    McManus DD, Gore J, Yarzebski J, Spencer F, Lessard D, Goldberg RJ (2011) Recent trends in the incidence, treatment, and outcomes of patients with STEMI and NSTEMI. Am J Med 124(1):40–47. CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Authors/Task Force Members, Roffi M, Patrono C, et al. (2015) ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: task force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. CrossRefGoogle Scholar
  4. 4.
    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. Circulation 130(25):e344–e426. CrossRefPubMedGoogle Scholar
  5. 5.
    Korff S, Katus HA, Giannitsis E (2006) Differential diagnosis of elevated troponins. Heart 92(7):987–993. CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Zhelev Z, Hyde C, Youngman E et al (2015) Diagnostic accuracy of single baseline measurement of Elecsys Troponin T high-sensitive assay for diagnosis of acute myocardial infarction in emergency department: systematic review and meta-analysis. BMJ 350:h15. CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Corsini A, Vagnarelli F, Bugani G et al (2015) Impact of high-sensitivity Troponin T on hospital admission, resources utilization, and outcomes. Eur Heart J Acute Cardiovasc Care 4(2):148–157. CrossRefPubMedGoogle Scholar
  8. 8.
    Al-Saleh A, Alazzoni A, Al Shalash S et al (2014) Performance of the high-sensitivity troponin assay in diagnosing acute myocardial infarction: systematic review and meta-analysis. CMAJ Open 2(3):E199–E207. CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Singer AJ, Ardise J, Gulla J, Cangro J (2005) Point-of-care testing reduces length of stay in emergency department chest pain patients. Ann Emerg Med 45(6):587–591. CrossRefPubMedGoogle Scholar
  10. 10.
    Lansky AJ, Stone GW (2010) Periprocedural myocardial infarction. Circ Cardiovasc Interv 3(6):602–610. CrossRefPubMedGoogle Scholar
  11. 11.
    Body R, Carley S, McDowell G, et al. The Manchester acute coronary syndromes (MACS) decision rule for suspected cardiac chest pain: derivation and external validation. Heart. heartjnl-2014-305564. CrossRefPubMedCentralGoogle Scholar
  12. 12.
    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(7):835–842CrossRefGoogle Scholar
  13. 13.
    Fox KAA, 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 (GRACE). BMJ 333(7578):1091. CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Mokhtari A, Lindahl B, Smith JG, Holzmann MJ, Khoshnood A, Ekelund U (2016) Diagnostic accuracy of high-sensitivity cardiac troponin T at presentation combined with history and ECG for ruling out major adverse cardiac events. Ann Emerg Med 68(6):649–658.e3. CrossRefPubMedGoogle Scholar
  15. 15.
    Carlton EW, Khattab A, Greaves K (2015) Identifying patients suitable for discharge after a single-presentation high-sensitivity troponin result: a comparison of five established risk scores and two high-sensitivity assays. Ann Emerg Med 66(6):635–645.e1. CrossRefPubMedGoogle Scholar
  16. 16.
    Poldervaart JM, Langedijk M, Backus BE et al (2017) Comparison of the GRACE, HEART and TIMI score to predict major adverse cardiac events in chest pain patients at the emergency department. Int J Cardiol 227:656–661. CrossRefPubMedGoogle Scholar
  17. 17.
    Chen X-H, Jiang H-L, Li Y-M, et al (2016) Prognostic values of 4 risk scores in Chinese patients with chest pain. Medicine (Baltimore) 95(52). CrossRefPubMedCentralGoogle Scholar
  18. 18.
    Six AJ, Backus BE, Kelder JC (2008) Chest pain in the emergency room: value of the HEART score. Neth Heart J Mon J Neth Soc Cardiol Neth Heart Found 16(6):191–196CrossRefGoogle Scholar
  19. 19.
    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(3):164–169. CrossRefPubMedGoogle Scholar
  20. 20.
    Six AJ, Cullen L, Backus BE et al (2013) The HEART Score for the Assessment of Patients With Chest Pain in the Emergency Department: a Multinational Validation Study. Crit Pathw Cardiol 12(3):121–126. CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    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(3):2153–2158. CrossRefPubMedGoogle Scholar
  22. 22.
    Poldervaart JM, Reitsma JB, Backus BE et al (2017) Effect of using the HEART score in patients with Chest Pain in the Emergency Department: a stepped-wedge, cluster randomized trial. Ann Intern Med 166(10):689–697. CrossRefPubMedGoogle Scholar
  23. 23.
    Thygesen K, Alpert JS, Jaffe AS et al (2012) Third universal definition of myocardial infarction. J Am Coll Cardiol 60(16):1581–1598. CrossRefPubMedGoogle Scholar
  24. 24.
    Body R, Cook G, Burrows G, Carley S, Lewis PS (2014) Can emergency physicians “rule in” and “rule out” acute myocardial infarction with clinical judgement? Emerg Med J EMJ 31(11):872–876. CrossRefPubMedGoogle Scholar
  25. 25.
    Body R, Carley S, McDowell G et al (2011) Rapid exclusion of acute myocardial infarction in patients with undetectable troponin using a high-sensitivity assay. J Am Coll Cardiol 58(13):1332–1339. CrossRefPubMedGoogle Scholar
  26. 26.
    Cullen L, Mueller C, Parsonage WA et al (2013) Validation of high-sensitivity troponin I in a 2-hour diagnostic strategy to assess 30-day outcomes in emergency department patients with possible acute coronary syndrome. J Am Coll Cardiol 62(14):1242–1249. CrossRefPubMedGoogle Scholar
  27. 27.
    Keller T, Zeller T, Ojeda F et al (2011) Serial changes in highly sensitive troponin I assay and early diagnosis of myocardial infarction. JAMA 306(24):2684–2693. CrossRefPubMedGoogle Scholar
  28. 28.
    Kline JA, Mitchell AM, Runyon MS, Jones AE, Webb WB (2005) Electronic medical record review as a surrogate to telephone follow-up to establish outcome for diagnostic research studies in the emergency department. Acad Emerg Med Off J Soc Acad Emerg Med 12(11):1127–1133. CrossRefGoogle Scholar
  29. 29.
    Hicks KA, Tcheng JE, Bozkurt B et al (2015) 2014 ACC/AHA key data elements and definitions for cardiovascular endpoint events in clinical trials. Circulation 132(4):302–361. CrossRefPubMedGoogle Scholar
  30. 30.
    Than M, Herbert M, Flaws D et al (2013) What is an acceptable risk of major adverse cardiac event in chest pain patients soon after discharge from the Emergency Department?: a clinical survey. Int J Cardiol 166(3):752–754. CrossRefPubMedGoogle Scholar
  31. 31.
    Kline JA, Johnson CL, Pollack CV et al (2005) Pretest probability assessment derived from attribute matching. BMC Med Inform Decis Mak 5:26. CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM (2004) Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost JTH 2(8):1247–1255. CrossRefPubMedGoogle Scholar
  33. 33.
    Kline JA, Courtney DM, Kabrhel C et al (2008) Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost JTH 6(5):772–780. CrossRefPubMedGoogle Scholar
  34. 34.
    Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD (2015) Evaluation of patients with suspected acute pulmonary embolism: best Practice advice from the clinical guidelines Committee of the American College of Physicians Evaluation of Patients With Suspected Acute Pulmonary Embolism. Ann Intern Med 163(9):701–711. CrossRefPubMedGoogle Scholar
  35. 35.
    Fesmire FM, Brown MD, Espinosa JA et al (2011) Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism. Ann Emerg Med 57(6):628–652.e75. CrossRefPubMedGoogle Scholar
  36. 36.
    Melki D, Jernberg T (2013) HEART score: a simple and useful tool that may lower the proportion of chest pain patients who are admitted. Crit Pathw Cardiol 12(3):127–131. CrossRefPubMedGoogle Scholar
  37. 37.
    Kocher KE, Meurer WJ, Desmond JS, Nallamothu BK (2012) Effect of testing and treatment on emergency department length of stay using a national database. Acad Emerg Med Off J Soc Acad Emerg Med 19(5):525–534. CrossRefGoogle Scholar
  38. 38.
    Combes C, Kadri F, Chaabane S (2014) Predicting Hospital length of stay using regression models: application to Emergency Department. In: 10ème Conférence Francophone de Modélisation, Optimisation et SimulationGoogle Scholar
  39. 39.
    Mahler SA, Riley RF, Hiestand BC et al (2015) The HEART pathway randomized trial. Circ Cardiovasc Qual Outcomes 8(2):195–203. CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Riley RF, Miller CD, Russell GB et al (2017) Cost analysis of the history, ECG, age, risk factors, and initial troponin (HEART) pathway randomized control trial. Am J Emerg Med 35(1):77–81. CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Bohyn E, Dubie E, Lebrun C et al (2014) Expeditious exclusion of acute coronary syndrome diagnosis by combined measurements of copeptin, high-sensitivity troponin, and GRACE score. Am J Emerg Med 32(4):293–296. CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    de Araújo Gonçalves P, Ferreira J, Aguiar C, Seabra-Gomes R (2005) TIMI, PURSUIT, and GRACE risk scores: sustained prognostic value and interaction with revascularization in NSTE-ACS. Eur Heart J 26(9):865–872. CrossRefGoogle Scholar
  43. 43.
    Cullen L, Greenslade J, Hammett CJ et al (2013) Comparison of three risk stratification rules for predicting patients with acute coronary syndrome presenting to an Australian emergency department. Heart Lung Circ 22(10):844–851. CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Söderholm M, Deligani MM, Choudhary M, Björk J, Ekelund U (2012) Ability of risk scores to predict a low complication risk in patients admitted for suspected acute coronary syndrome. Emerg Med J EMJ 29(8):644–649. CrossRefPubMedGoogle Scholar
  45. 45.
    Lyon R, Morris AC, Caesar D, Gray S, Gray A (2007) Chest pain presenting to the Emergency Department–to stratify risk with GRACE or TIMI? Resuscitation 74(1):90–93. CrossRefPubMedGoogle Scholar
  46. 46.
    Dubin J, Kiechle E, Wilson M, Timbol C, Bhat R, Milzman D (2017) Mean HEART scores for hospitalized chest pain patients are higher in more experienced providers. Am J Emerg Med 35(1):122–125. CrossRefPubMedGoogle Scholar

Copyright information

© SIMI 2018

Authors and Affiliations

  • Thomas Moumneh
    • 1
    Email author
  • Vanessa Richard-Jourjon
    • 2
  • Emilie Friou
    • 1
  • Fabrice Prunier
    • 3
  • Caroline Soulie-Chavignon
    • 1
  • Jacques Choukroun
    • 4
  • Betty Mazet-Guilaumé
    • 1
  • Jérémie Riou
    • 5
  • Andréa Penaloza
    • 6
  • Pierre-Marie Roy
    • 1
  1. 1.Institut MITOVASC, Département de Médecine d’UrgenceCHU d’Angers, Université d’AngersAngersFrance
  2. 2.Service de Médecine d’UrgenceCHU de PoitiersPoitiersFrance
  3. 3.Institut MITOVASC, Service de CardiologieCHU d’Angers, Université d’AngersAngersFrance
  4. 4.Service de Médecine d’UrgenceCH Le MansLe MansFrance
  5. 5.Unité de Formation-Recherche SantéUniversité d’Angers, MINT INSERM, UMR 6021AngersFrance
  6. 6.Service de Médecine d’UrgenceCliniques Universitaires St-LucBrusselsBelgium

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