Improving risk stratification in patients with chest pain: the Erlanger HEARTS3 score

doi:10.1016/j.ajem.2012.03.017

The American Journal of Emergency Medicine

Volume 30, Issue 9, November 2012, Pages 1829-1837

https://doi.org/10.1016/j.ajem.2012.03.017 Get rights and content

Abstract

Background

The HEART score uses elements from patient History, Electrocardiogram, Age, Risk Factors, and Troponin to obtain a risk score on a 0- to 10-point scale for predicting acute coronary syndromes (ACS). This investigation seeks to improve on the HEART score by proposing the HEARTS₃ score, which uses likelihood ratio analysis to give appropriate weight to the individual elements of the HEART score as well as incorporating 3 additional “S” variables: Sex, Serial 2-hour electrocardiogram, and Serial 2-hour delta troponin during the initial emergency department valuation.

Methods

This is a retrospective analysis of a prospectively acquired database consisting of 2148 consecutive patients with non–ST-segment elevation chest pain. Interval analysis of likelihood ratios was performed to determine appropriate weighting of the individual elements of the HEART₃ score. Primary outcomes were 30-day ACS and myocardial infarction.

Results

There were 315 patients with 30-day ACS and 1833 patients without ACS. Likelihood ratio analysis revealed significant discrepancies in weight of the 5 individual elements shared by the HEART and HEARTS₃ score. The HEARTS₃ score outperformed the HEART score as determined by comparison of areas under the receiver operating characteristic curve for myocardial infarction (0.958 vs 0.825; 95% confidence interval difference in areas, 0.105-0.161) and for 30-day ACS (0.901 vs 0.813; 95% confidence interval difference in areas, 0.064-0.110).

Conclusion

The HEARTS₃ score reliably risk stratifies patients with chest pain for 30-day ACS. Prospective studies need to be performed to determine if implementation of this score as a decision support tool can guide treatment and disposition decisions in the management of patients with chest pain.

Introduction

The HEART score was developed at a community hospital in the Netherlands in a patient population of 122 emergency department (ED) patients with chest pain to assist in the triage of patients with non–ST-segment elevation chest pain [1]. It uses elements from patient History, Electrocardiogram (ECG), Age, Risk factors for coronary artery disease (CAD), and Troponin levels. The 5 components were given a score of 0, 1, or 2, with little rationale given for the weighting of the score other than stating that the scores were “based on clinical experience and current medical literature.” The primary end point of the study was a composite of acute myocardial infarction (AMI), coronary revascularization, and death. The rates of composite end point in patients with scores of 0 to 3, 4 to 6, and 7 to 10 were 2.5%, 20.3%, and 72.7%, respectively. A subsequent prospective study in 880 patients with chest pain at 4 hospitals in the Netherlands found similar rates for the composite end point (measured at 6 weeks) of 1.0%, 11.6%, and 65.2%, respectively, in the 3 subgroups of patients [2]. Although the authors do not specifically state that patients with a HEART score of 3 or lower can be safely discharged home without further evaluation, they do state that the HEART score can be used in “triage” of patients with chest pain because it is a “reliable predictor of outcome.”

A drawback to the HEART score is that the individual variables were selected “based on clinical experience and current medical literature,” and weighting of the score was arbitrarily assigned without taking into account the likelihood of predicting adverse cardiac events. For example, 3 risk factors or age greater than 65 years has the same score (2 points) as having acute ischemia on the initial ECG or markedly elevated troponin, although these latter 2 findings are virtually diagnostic of acute coronary syndrome (ACS) in a patient with chest pain. Due to this lack of appropriate weighting, the HEART score has decreased discriminatory power, especially in patients with midrange scores. Another limitation of the HEART score is that it does not take into account the sex of the patient, although it is has been well established that there are significant age-related sex differences in determining the risk of CAD [3], [4], [5], [6]. Finally, the HEART score does not take advantage of the incremental information obtained when one obtains serial ECG and repeat cardiac marker measurements during the initial ED evaluation [7], [8].

This investigation seeks to improve on the HEART score by using likelihood ratio (LR) analysis to give appropriate weight to the individual elements of the HEART score, to create a HEART (weighted) score in risk stratifying patients with chest pain for 30-day ACS. This investigation also presents the HEARTS₃ score that incorporates 3 additional “S” variables into the HEART (weighted) score: Sex, Serial 2-hour ECG, and Serial 2-hour delta troponin testing during the initial ED evaluation.

Section snippets

Study design

This is a retrospective analysis of a prospectively acquired database of 2206 consecutive patients with chest pain presenting to the ED. This study was performed with approval of the institutional review committee.

Setting

This study was performed at an urban county hospital with an adult ED volume of approximately 45 000. The hospital has full cardiac capability with both interventional cardiologists and cardiothoracic surgery available 24 hours a day.

Study population

The study population consists of consecutive

Characteristics of study subjects

The study population was derived from a total of 2206 consecutive patients with chest pain presenting to our ED for evaluation. Fifty-eight patients with injury on the initial ECG were excluded, leaving a total patient population of 2148 patients. Table 1 provides the demographic characteristics in patients with and without 30-day ACS. Patients without 30-day ACS tended to be younger, be less likely to be white or male sex, and have lower rates of coronary risk factors and history of

Discussion

Various risk assessment scores and clinical prediction rules have been developed to assist the clinician in determining which patients are at higher risk for significant CAD and ACS [3], [4], [5], [6], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23]. The Framingham score was developed in a large population cohort to predict the 5- and 10-year risk of developing CAD [3]. The Hubbard-Ho and Morise score were developed to predict risk of CAD in patients referred for stress testing

Limitations

The primary limitation of our study is the retrospective design, although we feel that this limitation is offset by the fact that the data collection was prospectively performed in consecutive patients with chest pain undergoing a standardized chest pain evaluation protocol. Another major limitation is that the study used an older-generation troponin. Undoubtedly, newer-generation, high-sensitivity troponin assays would have resulted in more patients with diagnosis of MI as well as altering the

Conclusion

The HEART (weighted) and HEARTS₃ score outperform the HEART score in risk stratification of ED patients with chest pain. Future studies are needed to determine appropriate weighting of the troponin component of the HEARTS₃ score using high-sensitivity troponin assays as well as validating the weighting of the other individual elements used in the HEARTS₃ score. In addition, prospective studies investigating whether or not this score can be used as a decision support tool to assist ED physicians

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Cited by (35)

Utility of serial conventional troponin testing for emergency department patients stratified by HEART score and symptom timing
2023, American Journal of Emergency Medicine
The HEART score for risk stratifying chest pain patients in the emergency department (ED) has been widely adopted in clinical practice, but is often employed with nonconformant serial troponin measurements.
The primary objective of this study was to examine the utility of obtaining a second conventional 3-h troponin I (TnI) level in ED patients presenting with potential acute coronary syndrome (ACS), stratified by HEART score and duration of symptoms.
This was a retrospective cohort study of consecutive adult ED patients with a complete HEART score. We assessed the utility of repeat TnI measurement by examining the positivity rate of ΔTnI = [Second TnI] – [Initial TnI] stratified by HEART score and time elapsed since onset or resolution of symptoms. Major adverse cardiac events (MACE) within 6 weeks of index visit were assessed.
A total of 944 patients were included with 433 (45.9%) assigned a low risk HEART score 0–3. Of the 268 (61.9%) low risk HEART score patients receiving a second TnI, only 3 (1.1%, [0.2–3.2%]) resulted in a positive ΔTnI, one of which occurred in the setting of an elevated initial TnI. Overall, patients presenting within 3 h of symptoms were more likely to experience positive ΔTnI, index MACE and MACE at 6 weeks compared to patients presenting ≥3 h since symptoms onset/resolution and patients with unknown timing of symptoms (15.9% vs 11.0% vs 10.3%, p < 0.001; 10.0% vs 5.3% vs 4.6%, p = 0.021; 12.7% vs 6.6% vs 6.4%, p = 0.047).
Our data suggest serial measurement of conventional troponin provides limited added benefit in low risk HEART score patients, regardless of duration and timing of symptoms. Conversely, serial troponin measurement may confer utility in moderate/high risk HEART score patients, particularly those presenting within 3 h of symptoms.
A Methodological Appraisal of the HEART Score and Its Variants
2021, Annals of Emergency Medicine
Citation Excerpt :
We herein refer to the “HEART score” in its common 10-point configuration (Figure 1), and note variant modifications that have been described: The “HEARTS3 score” is the HEART score plus sex plus a repeat ECG and troponin measurement 2 hours after the first.9 The “HEAR score” (ie, HEART without the troponin) is the HEART score omitting the “T” component, ie, excluding any consideration of troponin measurement.10,11
We performed a methodological appraisal of the history, electrocardiogram, age, risk factors, and troponin (HEART) score and its variants in the context of Annals of Emergency Medicine’s methodological standards for clinical decision rules. We note that this chest pain risk stratification tool was not formally derived, omits sex and other known predictors, has weak interrater reliability, and its 0, 1, and 2 score weightings do not align with their known predictivities. Its summary performance (pooled sensitivities of 96% to 97% with lower confidence interval bounds of 93% to 94%) is below that which emergency physicians state a willingness to accept, below the 98% sensitivity exhibited by baseline practice without the score, and below the 1% to 2% acceptable miss threshold specified by the American College of Emergency Physicians chest pain policy. Two variants (HEART Pathway, HEART-2) have the same inherent structural limitations and demonstrate slightly better but still suboptimal sensitivity. Although a simple prediction tool for chest pain outcomes is appealing, we believe that the widespread use of the HEART score and its variants should be reconsidered.
HEART Score Risk Stratification of Low-Risk Chest Pain Patients in the Emergency Department: A Systematic Review and Meta-Analysis
2019, Annals of Emergency Medicine
The objectives of this systematic review and meta-analysis are to appraise the evidence in regard to the diagnostic accuracy of a low-risk History, ECG, Age, Risk Factors, and Troponin (HEART) score for prediction of major adverse cardiac events in emergency department (ED) patients. These included 4 subgroup analyses: by geographic region, the use of a modified low-risk HEART score (traditional HEART score [0 to 3] in addition to negative troponin results), using conventional versus high-sensitivity troponin assays in the HEART score, and a comparison of different post–ED-discharge patient follow-up intervals.
We searched MEDLINE, EBSCO, Web of Science, and Cochrane Database for studies on the diagnostic performance of low-risk HEART scores to predict major adverse cardiac events among ED chest pain patients. Two reviewers independently screened articles for inclusion, assessed the quality of studies with both an adapted Quality Assessment of Diagnostic Accuracy Studies version 2 tool and an internally developed tool that combined components of the Quality in Prognostic Studies; Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies; and Grading of Recommendations Assessment, Development and Evaluation. Pooled sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios were calculated.
There were 25 studies published from 2010 to 2017, with a total of 25,266 patients included in the final meta-analysis, of whom 9,919 (39.3%) were deemed to have low-risk HEART scores (0 to 3). Among patients with low-risk HEART scores, short-term major adverse cardiac events (30 days to 6 weeks) occurred in 2.1% of the population (182/8,832) compared with 21.9% of patients (3,290/15,038) with non–low-risk HEART scores (4 to 10). For patients with HEART scores of 0 to 3, the pooled sensitivity of short-term major adverse cardiac event predictions was 0.96 (95% confidence interval [CI] 0.93 to 0.98), specificity was 0.42 (95% CI 0.36 to 0.49), positive predictive value was 0.19 (95% CI 0.14 to 0.24), negative predictive value was 0.99 (95% CI 0.98 to 0.99), positive likelihood ratio was 1.66 (95% CI 1.50 to 1.85), and negative likelihood ratio was 0.09 (95% CI 0.06 to 0.15). Subgroup analysis showed that lower short-term major adverse cardiac events occurred among North American patients (0.7%), occurred when modified low-risk HEART score was used (0.8%), or occurred when high-sensitivity troponin was used for low-risk HEART score calculations (0.8%).
In this meta-analysis, despite its use in different patient populations, the troponin type used, and timeline of follow-up, a low-risk HEART score had high sensitivity, negative predictive value, and negative likelihood ratio for predicting short-term major adverse cardiac events, although risk of bias and statistical heterogeneity were high.
A HEART Pathway pitfall in an admitted patient
2019, American Journal of Emergency Medicine
Citation Excerpt :
Ruling out acute coronary syndrome (ACS) is imperative but the emergency physician must also determine if these patients require risk stratification for future adverse cardiac events. Though many other scoring systems have been tested, the HEART Score and subsequently, the HEART Pathway have emerged as the prominent decision making aid in the disposition of patients presenting for chest pain [3-8]. The HEART Score is a 5 component decision making tool with each component assigned a score of 0, 1, or 2 for total possible scores ranging between 0 and 10.
This paper discusses a possible weakness of the HEART Pathway specific to patients identified as high risk, requiring admission for inpatient risk stratification. Emergency Department (ED) crowding is at an all-time high and the possibility that many of these patients will board in the ED for a period of time before they are transported to an inpatient ward is becoming more likely. Given troponins peak at 6 h after the initial cardiac injury, it is plausible an initial troponin could still remain negative upon arrival. Extending the HEART Pathway to include a 3-hour delta troponin for admitted patients boarded in the emergency department may help alert the patient's inpatient team of those requiring more aggressive evaluations or more timely interventions. The case discussed herein highlights the course of a patient who was admitted to a medicine floor for chest pain along the HEART Pathway. After remaining in the ED for 3 h following admission a second troponin was drawn that resulted in the diagnosis of a non-ST segment myocardial infarction. The patient then received further management in the ED and a change in admission to the Cardiac Care Unit instead of the medicine floor. The patient ultimately received a Coronary Artery Bypass Graft during admission. If the patient had not had the second troponin while in the ED this care would have been delayed.
Impact of the HEART Pathway on Admission Rates for Emergency Department Patients with Chest Pain: An External Clinical Validation Study
2018, Journal of Emergency Medicine
Citation Excerpt :
Figure 1 demonstrates the HEART score as used in the HEART pathway. Several external validation studies demonstrate the HEART score's accuracy for predicting 6-week major adverse cardiac event (MACE, including mortality, nonfatal acute myocardial infarction [MI], and coronary revascularization) (12–16). In 2015, Mahler et al. first described a disposition algorithm based on the HEART score, which they termed the “HEART pathway” (17).
Chest pain is a common emergency department (ED) chief complaint. Safe discharge mechanisms for low-risk chest pain patients would be useful.
To compare admission rates prior to and after implementation of an accelerated disposition pathway for ED patients with low-risk chest pain based upon the HEART (History, ECG, Age, Risk factors, Troponin) score (HEART pathway).
We conducted an impact analysis of the HEART pathway. Patients with a HEART score ≥ 4 underwent hospital admission for cardiac risk stratification and monitoring. Patients with a HEART score ≤ 3 could opt for discharge with 72-h follow-up in lieu of admission. We collected data on cohorts prior to and after implementation of the new disposition pathway. For each cohort, we screened the charts of 625 consecutive chest pain patients. We measured patient demographics, past medical history, vital signs, HEART score, disposition, and 6-week major adverse cardiac events (MACE) using chart review methodology. We compared our primary outcome of hospital admission between the two cohorts.
The admission rate for the preintervention cohort was 63.5% (95% confidence interval [CI] 58.7–68.2%), vs. 48.3% (95% CI 43.7–53.0%) for the postintervention cohort. The absolute difference in admission rates was 15.3% (95% CI 8.7–21.8%). The odds ratio of admission for the postintervention cohort in a logistic regression model controlling for demographics, comorbidities, and vital signs was 0.48 (95% CI 0.33–0.66). One postintervention cohort patient leaving the ED against medical advice (HEART Score 4) experienced 6-week MACE.
The HEART pathway may provide a safe mechanism to optimize resource allocation for risk-stratifying ED chest pain patients.
An end-user's guide to the HEART score and pathway
2017, American Journal of Emergency Medicine
Citation Excerpt :
One study modified the score by weighing male gender separately, as well as obtaining serial troponins and ECGs over 2 h [46]. This is known as the HEARTS(3) score [46]. The S(3) correlates to sex, serial 2 h ECG, and serial 2 h delta troponin.
Chest pain accounts for a significant percentage of emergency department (ED) presentations. The HEART score and pathway have demonstrated an ability to appropriately risk stratify and discharge from the ED a significant proportion of patients.
This review evaluates vital components of the HEART score and pathway, while discussing important considerations for current and future use.
Chest pain is a common ED presentation, and several conditions associated with chest pain result in patient morbidity and mortality. One major disease is acute coronary syndrome (ACS). Despite the fear associated with this disease, it accounts for a minority of patients with chest pain in the ED. Emergency physicians rarely miss myocardial infarction (MI) or ACS, with miss rates < 1%. Many have sought a score and pathway that allow physicians to safely and reliably risk stratify patients. The HEART score and pathway have revolutionized chest pain evaluation, as they can risk stratify a significant number of patients accurately into separate categories based on history, electrocardiogram (ECG), troponin, age, and risk factors while displaying high sensitivity for MACE. Several intricacies must be considered in the use of this score including risk factors, ECG, troponin, age, history, gestalt, follow up, borderline score, and shared decision making. The HEART pathway can supplement clinician decision making.
Appropriate use of the HEART pathway reliably risk stratifies patients. Physicians must consider several key components when utilizing the HEART pathway, and future directions may incorporate other patient factors.

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Original ContributionImproving risk stratification in patients with chest pain: the Erlanger HEARTS3 score

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Study design

Setting

Study population

Characteristics of study subjects

Discussion

Limitations

Conclusion

Mayo Clin Proc

Am J Med

Am J Emerg Med

Ann Emerg Med

Ann Emerg Med

Am Heart J

Ann Emerg Med

J Am Coll Cardiol

Ann Emerg Med

Resuscitation

Chest pain in the emergency room: value of the HEART score

Neth Heart J

Chest pain in the emergency room: a multicenter validation of the HEART score

Crit Pathways Cardiol

An updated coronary risk profile: statement for health professionals

Circulation

Original Contribution
Improving risk stratification in patients with chest pain: the Erlanger HEARTS₃ score