Assessing the Utility of the HEART Score in the Era of High-Sensitivity Troponin
Ethan F Kramer1, Jonathan Van Name1,2, Rogina Rezk1
1From the College of Medicine, University of Florida, Gainesville, FL.
Insights
High-sensitivity troponin I (Hs-TnI) effectively rules out major adverse cardiac events (MACE) in emergency department patients with moderate or high HEART scores. A low Hs-TnI level indicates a very low risk of cardiac events, aiding clinical decisions.
Area of Science:
- Cardiology
- Emergency Medicine
- Biomarkers
Background:
- The HEART score is used to assess cardiovascular risk in patients with chest pain.
- Older troponin assays limit the HEART score's clinical utility.
- High-sensitivity troponin I (Hs-TnI) offers improved diagnostic accuracy.
Purpose of the Study:
- To evaluate if Hs-TnI alone can stratify cardiovascular risk in patients with moderate or high HEART scores.
- To determine the negative predictive value (NPV) of Hs-TnI in ruling out major adverse cardiac events (MACE).
Main Methods:
- Analysis of management and outcomes in adult patients presenting to the ED with chest pain.
- Inclusion criteria: moderate or high HEART score and Hs-TnI below the 99th percentile.
- Calculation of 30-day MACE incidence and NPV of Hs-TnI.
Main Results:
- The study included 1331 patients with moderate (92.0%) or high (8.0%) HEART scores.
- The 30-day incidence of MACE was low at 0.2%.
- Hs-TnI below the 99th percentile demonstrated a 99.8% NPV for ruling out MACE.
Conclusions:
- Hs-TnI is a reliable biomarker for excluding MACE in patients with moderate or high HEART scores.
- A moderate or high HEART score alone should not dictate admission if Hs-TnI is not elevated.
- Hs-TnI can refine risk stratification, potentially reducing unnecessary hospital admissions.
Background:
There is uncertainty in the clinical utility of the HEART score, given its incorporation of an older generation of troponin assay. We sought to determine whether high-sensitivity troponin I (Hs-TnI) alone can effectively stratify cardiovascular risk in patients presenting to the emergency department with moderate or high HEART score by analyzing the management and outcomes of adults presenting to our emergency department with chest pain, moderate or high HEART score, and Hs-TnI below the 99th percentile.
Methods:
For this population, we calculated the negative predictive value of Hs-TnI in ruling out a major adverse cardiac event (MACE; defined as myocardial infarction or death from a cardiovascular or unknown cause) at 30 days.
Results:
The average HEART score was 5.1, and 1224 patients (92.0%) had a moderate HEART score (4-6) and 107 patients (8.0%) had a high HEART score (7+). The average age of patients was 59.0 years and 52.7% were women. The incidence of 30-day MACE was 0.2%. Overall, in this cohort of patients with moderate or high HEART score, Hs-TnI below the 99th percentile had a negative predictive value of 99.8% (95% confidence interval: 99.6%-100.0%) in ruling out MACE at 30 days.
Conclusion:
Given the low event rate, a moderate or high HEART score should not be the sole determinant for admission when Hs-TnI is not elevated.
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