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Identifying Patients with Low Risk of Acute Coronary Syndrome Without Troponin Testing: Validation of the HEAR Score
Thomas Moumneh1, Benjamin C Sun2, Aileen Baecker3
1Département de Médecine d'Urgence, CHU d'Angers, Institut MITOVASC, UMR CNRS 6015 UMR INSERM 1083, Université d'Angers, Angers, France.
Insights
The HEAR score effectively identifies patients at very low risk for acute myocardial infarction or death, potentially eliminating the need for troponin testing. This validation supports its use in clinical practice for ruling out heart attacks.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Risk Stratification
Background:
- Current acute myocardial infarction diagnosis relies heavily on troponin testing, often necessitating emergency department visits.
- The HEAR score, derived from the HEART score, is a validated European risk tool.
- This study aimed to validate the HEAR score for ruling out acute myocardial infarction without biomarkers.
Purpose of the Study:
- To validate the HEAR score's efficacy in identifying patients who do not require biomarker testing for acute myocardial infarction.
- To assess the HEAR score's performance in a real-world clinical setting.
Main Methods:
- A retrospective cohort study was conducted across 15 emergency departments.
- Data from 22,109 adult patient encounters evaluated for acute myocardial infarction were analyzed.
- The HEAR score (0-8) was calculated, and 30-day outcomes (myocardial infarction or death) were tracked.
Main Results:
- Among 4106 patients with a HEAR score <2, only 0.1% experienced a 30-day myocardial infarction or death.
- The overall 30-day event rate for acute myocardial infarction or death was 1.1%.
- The HEAR score demonstrated high sensitivity (97.9%) for detecting events.
Conclusions:
- A low HEAR score accurately identifies patients with a very low risk of 30-day adverse cardiac events.
- This suggests that biomarker testing might be safely omitted for certain patients.
- Further research is recommended to evaluate the HEAR score's implementation in routine clinical practice.
Background:
Current guidelines for patients with suspected acute myocardial infarction are mainly based on troponin testing, commonly requiring an emergency department visit. HEAR score (History, Electrocardiogram, Age, and Risk factors) is a risk stratification tool validated in Europe, deduced from the HEART score (History, Electrocardiogram, Age, Risk factors, and Troponin), already implemented in clinical practice. We aimed to validate the HEAR score to rule out an acute myocardial infarction without needing biomarker testing.
Methods:
Retrospective cohort study at 15 emergency departments between May 2016 and December 2017. All adult encounters evaluated for possible acute myocardial infarction with a physician-documented HEART score for health plan members of Kaiser Permanente Southern California were included. Patients with an ST-segment elevation myocardial infarction, those under hospice care, or with a "do not resuscitate" status were excluded. HEAR scores from 0-8 were calculated for each encounter and used to report 30-day acute myocardial infarction or all-cause mortality for each score.
Results:
There were 22,109 patient encounters included in the study. Overall, 30-day acute myocardial infarction or death occurred in 1.1% of patients. Among the 4106 patients (19%) with a HEAR score <2, 3 died and 2 experienced an acute myocardial infarction within 30 days (0.1%; 95% confidence interval, 0.1-0.3). Sensitivity and specificity were 97.9% and 18.8%, respectively.
Conclusions:
A low HEAR score may accurately identify patients with a very low risk of 30-day acute myocardial infarction or death, representing a cohort of patients who might appropriately forego biomarker testing. Future research is warranted to assess the impact of implementing the HEAR score into routine clinical practice.
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