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History, ECG, Risk Factors (HER) Scoring for Cardiac Risk Stratification in Patients <45 Years of Age Presenting With
Christopher A Legare1, Erica Dunn1, Kate Arner2
1Emergency Medicine, St. Luke's University Health Network, Bethlehem, USA.
Insights
The HER score effectively rules out major adverse cardiac events in young patients with chest pain. This suggests troponin testing may be low yield for this demographic, improving emergency department efficiency.
Area of Science:
- Emergency Medicine
- Cardiology
- Clinical Risk Stratification
Background:
- Chest pain is a frequent emergency department chief complaint, with acute coronary syndrome (ACS) being an uncommon cause.
- Risk stratification tools are crucial for managing patients with chest pain, especially in younger populations.
Purpose of the Study:
- To evaluate the utility of the History, ECG, Risk Factors (HER) score in ruling out 30-day Major Adverse Cardiac Event (MACE), ACS, and other cardiac arrhythmias in patients under 45.
- To assess the HER score's effectiveness in predicting positive troponin results in this patient group.
Main Methods:
- Retrospective chart review of 7,724 patients presenting with chest pain over two years.
- HER scores categorized as negative (0-1) or positive (≥2).
- Calculation of sensitivity, specificity, and predictive values for HER score against primary cardiac disease and troponin results.
Main Results:
- The HER score demonstrated a high negative predictive value (99.8%) for significant primary cardiac disease in patients aged 18-45.
- HER score positivity was neither sensitive nor specific for predicting a positive troponin.
- A HER score of 0-1 had a negative predictive value of 99.5% for positive troponin.
Conclusions:
- The HER score, particularly a low score, is valuable in ruling out serious cardiac events in young patients with chest pain.
- Troponin testing appears to have low yield for risk stratification in patients under 45 with non-suspicious histories, minimal risk factors, and non-significant ECG findings.
- Clinical judgment combined with the HER score can potentially reduce unnecessary troponin testing in younger chest pain patients.
Abstract:
Background Chest pain is a common chief complaint of patients presenting to the emergency department. Acute coronary syndrome (ACS) is found to be the etiology of this symptom in a minority of these patient encounters. This study aimed to determine the utility of using the History, ECG, Risk Factors (HER) components of the History, ECG, Age, Risk Factors, Troponin (HEART) score in ruling out 30-day Major Adverse Cardiac Event (MACE), ACS, ventricular tachycardia, and ventricular fibrillation in patients aged less than 45. Additionally, the utility of this score in ruling out a positive troponin was investigated as well. Methodology This is a retrospective chart review study that examined a consecutive cohort of 7,724 patients presenting with chest pain to the 11 emergency departments of a single healthcare system over a two-year period (January 2019 to December 2020). HER scores of 0 to 1 were categorized as negative (-) and scores of two or greater were categorized as positive (+). Sensitivity, specificity, and predictive values were calculated for the relationship between HER score positivity and primary cardiac disease and troponin results. Results Test characteristics of HER scoring for significant primary cardiac disease in patients between 18 and 45 years of age presenting with undifferentiated chest pain were sensitivity of 88.0 (CI = 80.0-94.0), specificity of 72.6 (CI = 71.8-73.8), positive predictive value of 3.1 (CI = 2.4-3.9), and negative predictive value of 99.8 (CI = 99.7-99.9). Furthermore, an HER score >1 was neither sensitive nor specific in predicting a positive troponin (sensitivity = 80, CI = 71.9-86; specificity = 71.3, CI = 70.3-72.3). However, the negative predictive value of an HER score of 0-1 was 99.5 (CI = 99.3-99.7) and the positive predictive value was 4.7 (CI = 3.9-5.7). Conclusions According to this study, when evaluating young patients who are deemed to have a subjectively non-highly suspicious history, who have minimal risk factors, and who have an ECG without significant ST deviation, troponin testing is low yield in the risk stratification of patients under the age of 45 for serious primary cardiac disease.
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