Characteristics and Outcomes of Patients With a Moderate History, ECG, Age, Risk Factors, and Troponin (HEART) Score

Introduction Chest pain is a common, expensive cause of admission to the hospital from the Emergency Department (ED). The History, ECG, Age, Risk Factors, and Troponin (HEART) score is a risk stratification tool often used to determine the disposition of chest pain patients. This study evaluates the association of age, gender, HEART score, diabetes mellitus (DM), hypertension (HTN), hypercholesterolemia, family history (Fam Hx), and tobacco use with major adverse cardiovascular events (MACE) and hospital readmission. While low-risk HEART score patients are generally discharged and high-risk patients generally admitted, data is limited on the appropriate disposition strategy for moderate-risk patients. Our goal is to understand the risks of cardiovascular morbidity, the studies performed, and the factors associated with readmission in moderate HEART score patients. Methods A retrospective cohort study was conducted using ED records from March 1, 2018, to March 31, 2019. Patients with a moderate HEART score (4-6) were included. Data on additional testing and outcomes were collected. Statistical analyses included Pearson Chi-square tests and unadjusted and adjusted logistic regression to assess associations between explanatory variables and outcomes. Multicollinearity was assessed with all variance inflation factors below 1.3. To evaluate how well the logistic model performed an area under the curve (AUC) analysis was performed, with values of 0.68 (cardiovascular morbidity events) and 0.67 (readmission) respectively. No pre-existing AUC cutoff was used. Results The study included 959 patients with a moderate HEART score. The average age was 58.9 years, and 486 (50.7%) were male. Cardiovascular disease morbidity events occurred in 72 (7.5%) of patients, and 108 (11.3%) were readmitted within six weeks. Higher HEART scores, male gender, and diabetes were significantly associated with increased odds of cardiovascular morbidity. Male gender, tobacco use, and hypercholesterolemia were significantly associated with hospital readmission. The percutaneous intervention occurred in 60 (6.3%) patients, coronary bypass grafting in 10 (1.0%), and cerebrovascular accident in two (0.2%). Myocardial perfusion imaging was performed in 421 (43.9%) of patients and echocardiogram in 445 (46.4%), while computerized tomography coronary angiogram was performed in 99 (10.3%). No deaths were identified in our study. Discussion The findings suggest that higher HEART scores, male gender, and diabetes are significant predictors of cardiovascular morbidity, while male gender, tobacco use, and hypercholesterolemia predict hospital readmission. Reliance on ED records could limit study generalizability as we did not capture direct admissions. The retrospective design could introduce bias from confounding variables. Most of the testing and intervention during hospitalization could reasonably have been performed in an outpatient setting. Conclusion This study provides quantitative data on the utility of hospitalization for moderate-risk HEART score patients. The results support the potential for outpatient management in certain cases, especially those with HEART scores of 4. Future studies should include randomized controlled trials comparing the discharge of moderate HEART score patients with inpatient management.