Determining that a patient is at low risk of an Acute Coronary Syndrome and at low risk of a Major Adverse Cardiac Event is critical to efficient use of resources and also to maximizing the patient’s well being. Over investigation of patients who are truly at low risk can cause patient harm from diagnostic and therapeutic misadventures in addition to being costly to the system. Dr. Hick’s lecture is an outstanding help to all primary care physicians.
The following is from Dr. Chris Hicks lecture in Episode 64 Highlights from Whistler’s EmUpdate in EM Conference 2015 Part 2 [link is to the complete show notes and podcast] from Emergency Medicine Cases:
The Modified Heart Score for Low Risk Chest Pain
The original 5 point HEART Score from the Netherlands
For patients at low risk for Major Adverse Cardiac Events (MACE) in the ED setting (i.e. PCI, CABG, death).
This study used a single traditional troponin assay (not the high-sensitivity troponins that are increasingly being used) regardless of the timing of the troponin. Most EM providers would agree that a rate of MACE of 2.5% is not low enough to discharge patients from the ED. However, the Modified HEART Score lowered the risk of MACE to 0.6% by adding high sensitivity Troponins at 0 and 3 hours after arrival at the ED.
The Modified HEART Score
- HEART Score < 3, and
- Negative high sensitivity troponins at 0 and 3 hours
The rate of MACE in these patients was 0.6% within 6 weeks.
A subsequent study in March 2015 using the modified HEART score showed significant decreases in objective cardiac testing and median length of stay and increases in early discharge rates while maintaining a zero MACE rate at 30 days.
Another Approach to Low Risk Chest Pain (unpublished)
NICE (National Institute for Clinical Excellence) in the UK has suggested that negative high sensitivity troponins at 0 and 3 hours in any population, regardless of risk, may rule out ACS and patients can be discharged home for outpatient work up.
Additional FOAMed resources on the HEART Score & modified HEART score
ERCast with Amal Mattu
Key References from the lecture:
Backus BE, Six AJ, Kelder JC, et al. 2013. A prospective validation of the HEART score for chest patients at the emergency department. Int J of Cardiology, 168(3): 2153-8. Abstract
Mahler SA et al. The HEART Pathway Randomized Trial Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge. Circ Cardiovasc Qual Outcomes March 2015; 8 (2): 195 – 203. Abstract
Six AJ, Backus BE & Kelder JC. 2008. Chest pain in the emergency room: Value of the HEART score. Neth Heart J: 16(6): 191-6. Abstract