Elevated Major Adverse Cardiac Event (MACE) Risk With a HEART Score of 3: A Single-Site Retrospective Validation
David R Janese1, Marshall Byun-Andersen1, Danielle Handrop1
1Emergency Medicine/Family Medicine, Louisiana State University Health Shreveport, Shreveport, USA.
Insights
The HEART pathway
Area of Science:
- Emergency Medicine
- Cardiology
- Clinical Decision Support
Background:
- The HEART pathway is a standard tool for assessing chest pain patients in the emergency department (ED).
- A HEART score of 3 or less is typically considered low risk, guiding safe patient discharge.
- Evaluating the HEART pathway's performance in diverse settings is crucial for refining risk stratification.
Purpose of the Study:
- To assess the HEART pathway's accuracy in an urban academic ED.
- To determine the rate of major adverse cardiac events (MACE) in patients with a HEART score of 3.
- To compare observed MACE rates with the established low-risk threshold.
Main Methods:
- Retrospective chart review of 1,284 chest pain visits.
- Data collection included HEART scores, demographics, and 90-day MACE outcomes.
- Non-parametric statistical methods were used for analysis.
Main Results:
- Overall, 6.2% of patients experienced MACE within 90 days.
- Patients with a HEART score of 3 or less had a 4.4% MACE rate.
- HEART score positively correlated with MACE (ρ = 0.223, p < 0.001).
Conclusions:
- A HEART score of 3 is associated with a MACE rate exceeding the 2% low-risk threshold.
- Clinicians should exercise caution when discharging patients with a HEART score of 3.
- Further research is needed to optimize the interpretation of the HEART score at critical thresholds.
Objective:
The HEART pathway is a widely used clinical decision-making tool to risk-stratify patients presenting with chest pain in the emergency department (ED). A HEART score of 0-3 is generally accepted as "low risk," often serving as a threshold for safe discharge. This study aimed to evaluate the performance of the HEART pathway in an urban academic ED and determine the associated rate of major adverse cardiac events (MACE) at a HEART score of 3. MACE were defined as all-cause mortality, cardiovascular death, myocardial infarction, heart failure hospitalization, or stroke within 90 days.
Methods:
We conducted a retrospective chart review of 1,284 ED visits for chest pain from September 1, 2017, to August 31, 2018, at Louisiana State University Health Shreveport (LSUHS), Shreveport, Louisiana. HEART scores, demographics, and 90-day MACE outcomes were collected and analyzed using non-parametric statistical methods.
Results:
Of 1,284 patients, 79 (6.2%) experienced MACE. Among patients with a HEART score of 3 or less, the MACE rate was 4.4% using Wilcoxon's rank-sum test (p < 0.001). The HEART score showed a positive correlation with MACE using Spearman's rank correlation coefficient (ρ = 0.223, p < 0.001). Age correlated moderately with the HEART score (ρ = 0.568), but not with MACE. Gender showed no significant correlation with either HEART score or MACE outcomes.
Conclusion:
A HEART score of 3 was associated with a MACE rate higher than the traditionally accepted 2% threshold for low risk. Clinicians should approach disposition decisions for these patients with caution and consider shared decision-making and observation. Further research is needed to refine HEART score interpretation at this critical threshold.
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