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Performance of a simplified HEART score and HEART-GP score for evaluating chest pain in urgent primary care
R E Harskamp1,2, M Kleton3, I H Smits3
1Department of General Practice, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences and Amsterdam Public Health Research Institutes, Academic Medical Centre, Amsterdam, The Netherlands. r.e.harskamp@gmail.com.
Insights
Modified HEART scores, including the simplified HEART and HEART-GP (physician’s sense of alarm), effectively stratify chest pain risk in primary care. These tools aid in identifying urgent cases without routine troponin testing, improving diagnostic accuracy.
Area of Science:
- Cardiology
- Primary Care Medicine
- Diagnostic Accuracy
Background:
- Chest pain is a frequent symptom in urgent primary care settings, presenting diagnostic challenges.
- Differentiating between urgent and non-urgent causes of chest pain is crucial for timely intervention.
- Modified HEART score versions, omitting troponin (simplified HEART) or incorporating physician's 'sense of alarm' (HEART-GP), show potential for risk stratification.
Purpose of the Study:
- To evaluate the diagnostic accuracy of modified HEART score versions in primary care for chest pain patients.
- To assess the utility of the simplified HEART score and the HEART-GP score in risk stratification.
- To compare the performance of these modified scores against traditional clinical judgment in identifying major adverse cardiac events (MACEs).
Main Methods:
- Retrospective observational cohort study of 664 patients presenting with chest pain at an out-of-hours primary care facility.
- Six-week follow-up for major adverse cardiac events (MACEs).
- Analysis of diagnostic accuracy, including positive predictive value (PPV) and negative predictive value (NPV) for simplified HEART and HEART-GP scores.
Main Results:
- The HEART-GP score demonstrated higher diagnostic accuracy (C-statistic 0.90) compared to the simplified HEART score (C-statistic 0.86).
- Optimal diagnostic thresholds identified were simplified HEART score ≥2 (NPV 99.7%) and HEART-GP score ≥3 (NPV 99.7%).
- Utilizing these scores could potentially reduce unnecessary referrals while maintaining high sensitivity for MACE detection.
Conclusions:
- Modified HEART scores, particularly HEART-GP incorporating physician's 'sense of alarm', are valuable tools for chest pain risk stratification in primary care.
- These scores are effective in settings lacking routine troponin assay access.
- Further validation studies are recommended to confirm the clinical utility and generalizability of these modified HEART scores.
Background:
Chest pain is a common symptom in urgent primary care. The distinction between urgent and non-urgent causes can be challenging. A modified version of the HEART score, in which troponin is omitted ('simplified HEART') or replaced by the so-called 'sense of alarm' (HEART-GP), may aid in risk stratification.
Method:
This study involved a retrospective, observational cohort of consecutive patients evaluated for chest pain at a large-scale, out-of-hours, regional primary care facility in the Netherlands, with 6‑week follow-up for major adverse cardiac events (MACEs). The outcome of interest is diagnostic accuracy, including positive predictive value (PPV) and negative predictive value (NPV).
Results:
We included 664 patients; MACEs occurred in 4.8% (n = 32). For simplified HEART and HEART-GP, we found C‑statistics of 0.86 (95% confidence interval (CI) 0.80-0.91) and 0.90 (95% CI 0.85-0.95), respectively. Optimal diagnostic accuracy was found for a simplified HEART score ≥2 (PPV 9%, NPV 99.7%), HEART-GP score ≥3 (PPV 11%, NPV 99.7%) and HEART-GP score ≥4 (PPV 16%, NPV 99.4%). Physicians referred 157 patients (23.6%) and missed 6 MACEs. A simplified HEART score ≥2 would have picked up 5 cases, at the expense of 332 referrals (50.0%, p < 0.001). A HEART-GP score of ≥3 and ≥4 would have detected 5 and 3 MACEs and led to 293 (44.1%, p < 0.001) and 186 (28.0%, p = 0.18) referrals, respectively.
Conclusion:
HEART-score modifications including the physicians' 'sense of alarm' may be used as a risk stratification tool for chest pain in primary care in the absence of routine access to troponin assays. Further validation is warranted.
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