Heart Score

Dr. Chuck Chan

edited by Sophie Stempel

Background

Chest pain in the ED is the 2nd most common complaint and accounts for 10% of all visits. There is value in history taking, but alone it cannot rule out chest pain. The HEART score is a low-risk chest pain clinical decision tool in the ED. The limitations of the HEART score include its reliability on pretest probability, overestimation of ACS in patients with two sets of negative troponin and EKG, and the fact that one can have an elevated troponin and still be considered low risk on the HEART score. Newer studies have found serial troponins and single cardiac troponin useful in ruling out 30-day MACE.

Articles

Six, A. J., Backus, B. E., & Kelder, J. C. (2008). Chest pain in the emergency room: value of the HEART score. Netherlands Heart Journal, 16(6), 191-196.

Chew, Derek P., et al. "A randomized trial of a 1-hour troponin T protocol in suspected acute coronary syndromes: the rapid assessment of possible acute coronary syndrome in the emergency department with high-sensitivity troponin T study (RAPID-TnT)." Circulation 140.19 (2019): 1543-1556.

Study Designs

Heart Score Study: This was a retrospective cohort study. It consisted of 122 patients in a 265- bed hospital in the Netherlands. The study ran from January 1, 2006, until March 31st, 2006. The results were validated by multiple independent research groups and outperforms alternative decision-making tools such as TIMI and GRACE.


High Sensitivity Troponin (RAPID trial): This was a multicenter randomized control trial. There were 3,378 participants.


Single Cardiac Troponin (Wassie et. al): This was a retrospective cohort study with 27,918 participants.

Results

Heart Score Study:

The percentage of individuals who reached one of the specified endpoints was measured. The endpoints used were:

AMI

PCI

CABG

Death + endpoint

The study found that from the individuals with a HEART score of 0-3, 2.5% reached endpoint. Of the individuals with a HEART score 4-6, 20.3% reached endpoint. Of the individuals with a HEART score of 7-10 73% reached endpoint.


RAPID Trial (Chew et. al):

This study found that 0/1 hour troponin was non-inferior to 0/3 hour high sensitivity troponin in ruling out 30-day MACE.


Wassie et al:

This study found that single cardiac troponin was non-inferior to serial cardiac troponin in ruling out 30-day MACE.

Application

  • HEART score is still the best clinical decision tool in ED for low-risk chest pain

  • Newer studies suggest single negative high-sensitivity troponin or 0/1h serial troponins are non-inferior to 0/3h serial troponin in 30-day MACE

References

Chew, Derek P., et al. "A randomized trial of a 1-hour troponin T protocol in suspected acute coronary syndromes: the rapid assessment of possible acute coronary syndrome in the emergency department with high-sensitivity troponin T study (RAPID-TnT)." Circulation 140.19 (2019): 1543-1556.

DeVon, Holli A., et al. "Sensitivity, specificity, and sex differences in symptoms reported on the 13‐item acute coronary syndrome checklist." Journal of the American Heart Association 3.2 (2014): e000586.

Helman, A. McRae, A. Lang, E. Low Risk Chest Pain and High Sensitivity Troponin – A Paradigm Shift. Emergency Medicine Cases. July, 2019. https://emergencymedicinecases.com/low-risk-chest-pain-high-sensitivity-troponin. Accessed Sept 4 2021.

Hess, Erik P., et al. "Development of a clinical prediction rule for 30-day cardiac events in emergency department patients with chest pain and possible acute coronary syndrome." Annals of emergency medicine 59.2 (2012): 115-125.

Salim Rezaie, "Chest Pain: What is the Value of a Good History?", REBEL EM blog, November 1, 2013. Available at: https://rebelem.com/chest-pain-value-good-history/.

Six, A. J., Backus, B. E., & Kelder, J. C. (2008). Chest pain in the emergency room: value of the HEART score. Netherlands Heart Journal, 16(6), 191-196.

Switaj, Timothy L., Scott Christensen, and Dean M. Brewer. "Acute coronary syndrome: current treatment." American family physician 95.4 (2017): 232-240.