The HEART Score: A New ED Chest Pain Assessment Tool

Salim R. Rezaie, MDAssistant Program Director of Emergency Medicine

Assistant Clinical Professor of Emergency Medicine/Internal Medicine

UTHSCSA, San Antonio, TX

Objectives

Discuss Chest Pain Risk Stratification Tools & Their Limitations

What is the HEART Score?

What is the Evidence for the HEART Score in the ED

Are there other Risk Stratification Scores to Know About

Disclosures

Chest Pain Risk Stratification ToolsRisk Score

Year of Publication

Score Range

Score Predicts C-Statistic of Original Study

PURSUIT 2000 1 - 18 Risk of death/MI at 30 days after admission

0.84 (death) and 0.67 (death/MI)

TIMI 2000 0 - 7 Risk of all cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization within 14 days after admission

0.65

GRACE 2003 1 - 372 Risk of hospital death and post-discharge death at 6 months

0.83

FRISC 2004 0 - 7 Treatment effect of early invasive strategies in ACS

0.77 (death) and 0.7 (death/MI)

HEART 2008 0 - 10 Prediction of combined endpoint of MI, PCI, CABG or Death within 6 weeks after presentation

0.9

C-Statistic

Probability that outcome is better than chance

Range: 0.5 to 1.0

0.5 = no better than chance

1.0 = perfectly identifies those within a group and those not

≥0.7 = Model is reasonable

≥0.8 = Model is strong

Tru

e P

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False Positive Rate

Chest Pain Risk Stratification ToolsRisk Score

Year of Publication

Score Range

Score Predicts C-Statistic of Original Study

PURSUIT 2000 1 - 18 Risk of death/MI at 30 days after admission

0.84 (death) and 0.67 (death/MI)

TIMI 2000 0 - 7 Risk of all cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization within 14 days after admission

0.65

GRACE 2003 1 - 372 Risk of hospital death and post-discharge death at 6 months

0.83

FRISC 2004 0 - 7 Treatment effect of early invasive strategies in ACS

0.77 (death) and 0.7 (death/MI)

HEART 2008 0 - 10 Prediction of combined endpoint of MI, PCI, CABG or Death within 6 weeks after presentation

0.9

PURSUIT Risk Score

NO TROPONIN Included

GRACE Risk Score

VERY COMPLEX

FRISC Score

BINARY SCORING SYSTEM

TIMI Risk Score

BINARY SCORING SYSTEM

Issues with Risk Scores

Risk Score Weaknesses

PURSUIT • Does not use troponin• Majority of Score Dependent on Patient Age

TIMI • Poor Predictive Power (i.e. c-statistic 0.65)

GRACE • Very Complex to Use• Large Portion of Score Dependent on Patient Age

FRISC • Poor Predictive Power (i.e. c-statistic 0.7)

None evaluated all comers (Only patients with ACS)

None derived for an ED patient population

What is the HEART Score?

H = History

E = ECG

A = Age

R = Risk Factors

T = Troponin

What is the Evidence for the HEART Score?

122 patients with CP

Predictive Value of HEART Score out to 3 months

Primary Endpoints:1. AMI

2. PCI

3. CABG

4. DEATH

Six AJ et al. Neth Heart J. 2008. PMCID: PMC2442661

Limitations:1. Pilot study

2. observational and retrospective

3. Single Center

4. Netherlands

5. Only 122 patients

Analysis

HEART Score

Risk of AMI, PCI, CABG, and/or Death Disposition

0 - 3 1/39 (2.5%) Discharge

4 - 6 12/59 (20.3%) Admission for Clinical Observation

≥7 16/22 (72.7%) Early Invasive Strategies

External Validation of HEART Score

2440 patients with CP

Multicenter (10 hospitals)

Compared to TIMI & GRACE scores (c-statistic)

Primary Endpoint:1. *Major Adverse

Cardiac Event (MACE) at 6 weeks

Secondary Endpoint:1. AMI and Death

2. ACS

3. PCI

Backus BE et al. International Journal of Cardiology 2013. PMID: 23465250

*AMI, PCI, CABG, & Death

Analysis

HEART Score Risk of MACE Original Study

0 - 3 1.7% 2.5%

4 - 6 16.6% 20.3%

≥7 50.1% 72.7%

Other Thoughts

Limitations:1. 45 patients lost to

follow-up

2. Netherlands

A New Risk Score? EDACS-ADP

Emergency Department Assessment of Chest Pain Score (EDACS) – Identified 6 Predictors

Accelerated Diagnostic Protocol (ADP)

Than M et al. Emergency Medicine Australasia 2014. PMID: 24428678

What they did…

Develop a Score to predict 30d risk of MACE in ED setting

Develop and Validate a CP risk score + ADP to safely increase patients suitable for early discharge

Identify statistical predictors (37) for MACE

AMI, PCI, CV mortality, ventricular arrhythmia, cardiogenic shock, or high AV block

Use clinician feedback to improve clinical plausibility

Derivation – 1974 patients

Validation – 608 patients

Predictor P Value Odds Ratio

Age <0.0001 1.5 (Per 10 years)

Male <0.0001 2.110

Diaphoresis 0.0038 1.460

Pain radiates to arm (or shoulder)

<0.0001 1.850

Pain on inspiration 0.0190 0.630

Pain on palpation 0.0379 0.470

www.rebelem.com Chest Pain: The Value of a Good History

AnalysisSensitivity Specificity Identification of Low Risk Patients

for MACE

Derivation 99.0% 49.9% 42.2%

Validation 100% 59.0% 51.3%

Other Thoughts

Limitations:1. Predominantly

Caucasian, older males

2. Feedback from clinicians was a convenience sample

3. Validation done with phone calls and chart reviews

Conclusions

TIMI, GRACE, PURSUIT, & FRISC scores evaluate high risk patients (i.e. ACS) & not derived in ED populations

HEART Score is derived in an ED population of all comers with chest pain and superior to TIMI score

Need a US validation study before 100% implementation

Maybe in the pipeline…EDACS-ADP Risk Score

Bibliography

1. Backus BE et al. A Prospective Validation of the HEART Score for Chest Pain Patients at the Emergency Department. International Journal of Cardiology 2013; 168: 2153 – 58.

2. Backus BE et al. Risk Scores for Patients with Chest Pain: Evaluation in the Emergency Department. Current Cardiology Reviews, 2011; 7: 2 – 8.

3. Six AJ et al. Chest Pain in the Emergency Room: Value of the HEART Score. Neth Heart J 2008;16: 191- 6.

4. Than M et al. Development and Validation of the Emergency Department Assessment of Chest Pain Score and 2h Accelerated Diagnostic Protocol. Emergency Medicine Australasia 2014; 26: 34 – 44.

Questions?

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