HEART Score of Four for Age and Risk Factors: A Case Series

Chest pain is a frequent chief complaint in the ED. Identifying acute coronary syndrome (ACS) and establishing proper disposition for further risk assessment for major adverse cardiac events are paramount. The HEART Score is a key decision-making tool used to determine patient risk and disposition. One scenario with a potential drawback of the HEART Score is found in patients with a score of four based solely on age and risk factors. The HEART Score categorizes a score of three or less as low risk, and patients with scores above this threshold are typically admitted. We present six cases of chest pain presenting to a military emergency department with a score of four based solely on age and risk factors. They represent every such case found in a previously created database used to validate the HEART Score. We followed each case forward one year in electronic medical records to identify major adverse cardiac events. With the exception of one case that was placed on hospice for non-cardiac reasons and subsequently lost to follow up, there were no adverse events. There is a rising concern for increasing hospital admission rates, overuse of resources, and cost. We highlight that this subset of HEART Score patients requires a more nuanced risk stratification in the ED. It may be worth the time and effort to risk stratify this subset with coronary computed tomography angiography. This additional effort may help reduce admission at such a patient's current and future presentations to the ED for chest pain.