Comparison of 3 Symptom Classification Methods to Standardize the History Component of the HEART Score
Michael R Marchick1, Michael L Setteducato, Jesse J Revenis
1*Department of Emergency Medicine, †College of Medicine, ‡Department of Biostatistics, Epidemiology and Research Design at CTSI, §Department of Medicine, Division of Cardiology, University of Florida, Gainesville, Florida.
Insights
Objective scoring models for the HEART score showed different distributions but did not reliably identify chest pain patients needing further cardiac testing in this low-risk group. Further research is needed before adopting these objective HEART score models.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Risk Stratification
Background:
- The HEART score (History, Electrocardiography, Age, Risk factors, Troponin) is used for chest pain evaluation.
- The subjective nature of the HEART score's history component has raised concerns among clinicians.
- Objective scoring models were developed to address this subjectivity.
Purpose of the Study:
- To evaluate the association of three objective HEART score models with noninvasive cardiac testing results.
- To determine if objective HEART score components correlate with abnormal cardiovascular findings.
Main Methods:
- Retrospective review of medical records from chest pain center patients.
- Calculation of HEART scores using three distinct objective models.
- Analysis of HEART score distributions, inter-model agreement, and correlation with cardiac test outcomes.
Main Results:
- Seven hundred forty-nine patients were analyzed; 58 had abnormal cardiac tests.
- Mean HEART scores differed significantly across the three objective models (p < 0.001).
- No significant correlation was found between higher objective symptom component scores and abnormal cardiovascular tests (p = 0.09–0.86).
Conclusions:
- Objective HEART score models yielded varied score distributions but did not effectively identify patients with abnormal advanced cardiac studies in this low-risk cohort.
- The performance of these objective models in predicting abnormal cardiac findings was inadequate.
- Further studies are recommended to compare objective models with subjective history scoring in broader patient populations before clinical adoption.
Objectives:
The History, Electrocardiography, Age, Risk factors, Troponin (HEART) score enables rapid risk stratification of emergency department patients presenting with chest pain. However, the subjectivity in scoring introduced by the history component has been criticized by some clinicians. We examined the association of 3 objective scoring models with the results of noninvasive cardiac testing.
Methods:
Medical records for all patients evaluated in the chest pain center of an academic medical center during a 1-year period were reviewed retrospectively. Each patient's history component score was calculated using 3 models developed by the authors. Differences in the distribution of HEART scores for each model, as well as their degree of agreement with one another, as well as the results of cardiac testing were analyzed.
Results:
Seven hundred forty nine patients were studied, 58 of which had an abnormal stress test or computed tomography coronary angiography. The mean HEART scores for models 1, 2, and 3 were 2.97 (SD 1.17), 2.57 (SD 1.25), and 3.30 (SD 1.35), respectively, and were significantly different (P < 0.001). However, for each model, the likelihood of an abnormal cardiovascular test did not correlate with higher scores on the symptom component of the HEART score (P = 0.09, 0.41, and 0.86, respectively).
Conclusions:
While the objective scoring models produced different distributions of HEART scores, no model performed well with regards to identifying patients with abnormal advanced cardiac studies in this relatively low-risk cohort. Further studies in a broader cohort of patients, as well as comparison with the performance of subjective history scoring, is warranted before adoption of any of these objective models.
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