Associations Between Sex, Race/Ethnicity, and HEART Score Guideline Implementation for Cardiac Testing in the...

Disparities in emergency care for acute coronary syndrome (ACS) have been reported across sex and race/ethnicity. Evidence-based decision tools may help reduce these gaps if their components are objective. The history, electrocardiogram (ECG), age, risk factors, troponin levels (HEART) Score is a validated tool for cardiac risk stratification that may support more equitable care.

To assess whether HEART Score implementation in a large, urban, safety-net emergency department (ED) increased referral for guideline-recommended cardiac testing, and whether effects differed by sex or race/ethnicity.

We conducted a secondary analysis of a pre-post quasi-experiment evaluating HEART Score-based ACS guideline implementation. Adults (≥18 years) were included if they had a troponin completed and an ICD-10 code for chest pain or ACS. The primary outcome was appropriate referral, defined as HEART Score ≥4, no normal objective testing within the year, and receipt of ED testing, urgent outpatient testing ordered, or inpatient admission for testing. We calculated descriptive statistics and adjusted odds ratios (ORs) with 95% confidence intervals (CIs).

Among 1170 patients (521 preimplementation; 649 postimplementation), 498 had a HEART Score ≥4 and were included in the primary model. Implementation was associated with higher odds of appropriate referral (adjusted OR 2.74, 95% CI: 1.87-4.03). Sex and race/ethnicity were not independently associated with referral in either period (p = 0.23-0.76).

Implementation of the HEART Score was associated with increased odds of appropriate referrals for cardiac testing, with no observed disparities by sex, race, or ethnicity. Standardized risk stratification using the HEART Score may support more equitable ACS evaluation in the ED.