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Using HEART2 score to risk stratify chest pain patients in the Emergency Department: an observational study
Chet D Schrader1, Darren Kumar2, Yuan Zhou3
1Department of Emergency Medicine, John Peter Smith Health Network (JPS Health Network), 1500 S. Main St., Fort Worth, TX, 76104, USA.
Insights
The HEART2 score, incorporating cardiac imaging tests, improves risk stratification for chest pain patients in the emergency department, especially those with prior imaging. This enhanced HEART score allows for more accurate predictions of major adverse cardiac events.
Area of Science:
- Cardiology
- Emergency Medicine
- Medical Imaging
Background:
- Many emergency department (ED) chest pain patients have prior cardiac imaging tests (CIT).
- The HEART score (history, electrocardiogram, age, risk factors, troponin) is used for risk stratification but not specifically for patients with prior CIT.
- There is a need to refine risk assessment tools for chest pain patients with a history of cardiac imaging.
Purpose of the Study:
- To modify the HEART score by incorporating recent CIT findings, creating the HEART2 score.
- To predict 30-day major adverse cardiac events (MACE) in ED chest pain patients using the HEART2 score.
- To compare the predictive accuracy of the HEART and HEART2 scores, particularly in patients with previous CIT.
Main Methods:
- A single-center observational study included 9419 chest pain patients.
- A modified HEART2 score was developed, adding CIT findings to the original HEART score components.
- Patients were stratified into low, moderate, and high-risk groups based on HEART/HEART2 scores (≤3, 4-6, ≥7).
Main Results:
- Among 1874 patients with previous CIT, the HEART2 score identified a larger proportion as low-risk (55.5%) compared to the HEART score (38.2%).
- The overall performance accuracy of the HEART2 score for predicting 30-day MACE in patients with previous CIT was superior to the HEART score (AUC 0.74 vs. 0.71).
- MACE outcomes were similar between low-risk HEART and HEART2 groups (2.2% vs. 3.1%).
Conclusions:
- The HEART2 score may be suitable for risk-stratifying low-to-moderate risk chest pain patients in the ED.
- Utilizing the HEART2 score (≤3) could enable direct discharge for over 45% more chest pain patients with prior CIT.
- The HEART2 score offers improved accuracy in predicting MACE for chest pain patients with prior cardiac imaging.
Background:
A significant number of chest pain patients had previous cardiac imaging tests (CIT) performed before being presented to the Emergency Department (ED). The HEART (history, electrocardiogram, age, risk factors, and troponin) score has been used to risk-stratify chest pain patients in the ED, but not particularly for patients with CIT performed. We aim to modify the current HEART score with the addition of most recent CIT findings (referred to as HEART2 score), to predict a 30-day major adverse cardiac event (MACE) among ED chest pain patients, compare the performance accuracy of using HEART versus HEART2 score for 30-day MACE outcome predictions, and further determine the value of HEART2 in a subset group of ED chest pain patients (i.e., ones with previous CIT).
Methods:
This is a single-center observational study. We included chest pain patients with HEART scores calculated during their index ED visits. A modified HEART2 score was developed with the addition of CIT findings as one of the HEART2 components. Patients were divided into three groups, including low (≤ 3), moderate (4-6), and high-risk HEART/HEART2 scores (≥ 7). MACE occurrence of a patient with different risks of HEART and HEART2 scores and overall performance accuracy of HEART versus HEART2 score predicting MACE outcomes were compared.
Results:
We included a total of 9419 chest pain patients at ED, among which one out of five patients (1874/9419) had previous CIT performed. Fewer (38.2%) of such patients had low-risk HEART scores in comparison to 55.5% of low-risk HEART2 scores (p < 0.001). The MACE outcomes were similar in low-risk HEART patients compared with low-risk HEART2 patients (2.2% versus 3.1%, p = 0.3021). The overall performance accuracy of using the HEART2 score to stratify chest pain patients with previous CIT was better than using the HEART score's (AUC 0.74 versus 0.71, p = 0.0082).
Conclusions:
Using the HEART2 score might be suitable to stratify low-to-moderate risk chest pain patients at ED with a similar 30-days MACE occurrence compared to the HEART score. More importantly, with the use of similar low-risk criteria (HEART2 ≤ 3), over 45% more chest pain patients with previous CIT performed could be discharged directly from ED.
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