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The interobserver agreement of the HEART-score, a multicentre prospective study
Kirsten F van Meerten1, Rowan M A Haan1, Ineke M C Dekker2
1Emergency Department, Albert Schweitzer Ziekenhuis Dordrecht & Zwijndrecht.
Insights
The HEART-score shows moderate agreement between ambulance nurses and ED physicians for assessing cardiac risk. Further training is needed for prehospital nurses to accurately calculate the HEART-score for chest pain patients.
Area of Science:
- Emergency Medicine
- Cardiology
- Clinical Risk Assessment
Background:
- Chest pain is a frequent emergency department (ED) presentation.
- The HEART-score assesses 30-day risk for major adverse cardiac events (MACE).
- Reliability of prehospital HEART-score calculation is not well-established.
Purpose of the Study:
- To compare interobserver agreement of the HEART-score between ambulance nurses and ED physicians.
- To evaluate the reproducibility of HEART-score risk stratification in a prehospital setting.
Main Methods:
- Prospective enrollment of patients (≥18 years) with suspected cardiac chest pain presenting via ambulance.
- Comparison of HEART-scores calculated by ambulance nurses and ED physicians.
- Interobserver agreement measured using Cohen's Kappa (K); secondary endpoint: 30-day MACE.
Main Results:
- 307 patients enrolled; mean age 64.8 years.
- Moderate agreement (K=0.514 overall; K=0.591 for low-risk category) between nurses and physicians.
- 64 patients (21%) experienced MACE within 30 days; 7% MACE risk in nurse-identified low-risk group vs. 5% in physician-identified group.
Conclusions:
- Moderate interobserver agreement suggests current HEART-score use by ambulance nurses is not fully supported.
- Prehospital nurse training is crucial for accurate HEART-score calculation.
- Further research may refine prehospital risk assessment protocols.
Background And Importance:
Chest pain is one of the most common presentations to the emergency department (ED). The HEART-score is used to assess the 30-day risk of developing a major adverse cardiac event (MACE). The HEART-score enables clinicians to classify patients in low, intermediate, or high-risk groups though little is known as to whether this can be done reliably and reproducibly in a prehospital setting.
Objective:
The aim of this study was to compare the interobserver agreement of the HEART-score between ambulance nurses and ED physicians.
Design, Settings, And Participants:
Patients ≥18 years, with chest pain of suspected cardiac origin presented by ambulance to the EDs of four regional hospitals, were prospectively enrolled between October 2018 and April 2019.
Outcomes Measure And Analysis:
The primary endpoint was interobserver agreement of the HEART-scores calculated by ambulance nurses compared to those calculated by ED physicians. Agreement was measured using Cohen's Kappa (K) both for overall HEART-score and dichotomized HEART categories. A secondary endpoint was the occurrence of a MACE at 30 days after inclusion.
Main Results:
A total of 307 patients were enrolled of which 166 patients were male (54%). The mean age was 64.8 years. In 23% (95% confidence interval, 18-27), patients were scored in the low-risk category by both ambulance nurses and ED physicians. The K for the overall HEART-score compared between ambulance nurses and ED physicians was 0.514. The K for the low-risk category versus intermediate and high-risk category was 0.591. Both are defined as 'moderate'. MACE within 30 days occurred in 64 patients (21%). In the low-risk group as defined by the ambulance nurses, there was a 7% risk of MACE compared to an average 5% MACE risk in the ED physician group.
Conclusions:
The moderate interobserver agreement of the HEART-score does not currently support the use of the HEART-score by ambulance nurses in a prehospital setting. Training for prehospital nurses is vital to ensure that they are able to calculate the HEART-score accurately.
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