Prognostic Factors in Chest Pain Patients : A Quantitative Analysis of the HEART Score

OBJECTIVES: Risk stratification for chest pain patients at the emergency department is recommended in several guidelines. The history, ECG, age, risk factors, and troponin (HEART) score is based on medical literature and expert opinion to estimate the risk of a major adverse cardiac event. We aimed to assess the predictive effects of the 5 HEART components and to compare performances of the original HEART score and a model based on regression analysis. METHODS: We analyzed prospectively collected data from 2388 patients, of whom 407 (17%) had a major adverse cardiac event within 6 weeks (acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft, significant stenosis with conservative treatment and death due to any cause). RESULTS: Univariate regression analysis showed the same ordering of predictive effects as used in the HEART score. Based on multivariable logistic regression analysis, an adjusted score showed slightly better calibration and discrimination (c statistic HEART, 0.83, HEART-adj, 0.85). In comparison to HEART, HEART-adj proved in a decision curve analysis clinically useful for decision thresholds over 25%. Nevertheless, the original HEART classified patients better than HEART-adj (net reclassification improvement = 14.1%). CONCLUSION: The previously chosen weights of the 5 elements of the HEART score are supported by multivariable statistical analyses, although some improvement in calibration and discrimination is possible by adapting the score. The gain in clinical usefulness is relatively small and supports the use of either the original or adjusted HEART score in daily practice

Nanosized Sodium-doped Lanthanum Manganites: role of synthetic route on their physical properties

OBJECTIVE: The HEART score for the early risk stratification of patients presenting to the emergency department with chest pain contains 5 elements: history, electrocardiogram, age, risk factors, and troponin. It has been validated in The Netherlands. The purpose of this investigation was to perform an external validation of the HEART score in an Asia-Pacific population. METHODS: Data were used from 2906 patients presenting with chest pain to the emergency departments of 14 hospitals. HEART scores were determined retrospectively. Three risk groups were composed based on previous research. The predictive values for the occurrence of 30-day major adverse coronary events (MACE) were assessed. A comparison was made with the Thrombolysis in Myocardial Infarction (TIMI) score in terms of the value of C-statistics. RESULTS: The low-risk group, HEART score ≤3, consisted of 820/2906 patients (28.2%). Fourteen (1.7%) patients were incorrectly defined as low risk (false negatives). The high-risk population, HEART score 7-10, consisted of 464 patients (16%) with a risk of MACE of 43.1%. The C-statistics were 0.83 (0.81-0.85) for HEART and 0.75 (0.72-0.77) for TIMI (P CONCLUSIONS: Utilization of the HEART score provided excellent determination of risk for 30-day MACE, comparing well with the Thrombolysis in Myocardial Infarction score. This study externally validates previous findings that HEART is a powerful clinical tool in this setting. It quickly identifies both a large proportion of low-risk patients, in whom early discharge without additional testing goes with a risk of MACE of only 1.7%, and high-risk patients who are potential candidates for early invasive strategies.</p

The Fast and the Furious: Low-Risk Chest Pain and the Rapid Rule-Out Protocol

Accelerated diagnostic pathways (ADP) have been designed to identify low-risk chest pain patients in the emergency department. This review article discusses the Asia-Pacific Evaluation of Chest Pain Trial (ASPECT) score, the Accelerated Diagnostic Protocol for Chest Pain Trial (ADAPT) score, the Emergency Department Assessment of Chest Pain Score (EDACS), the HEARTScore and the HEART pathway. These ADPs have been validated in various studies and aid the emergency provider with identifying the low-risk chest pain patient who is appropriate for discharge home, while at the same time highlighting those patients who would benefit from further in-patient work up. These approaches should be paired with patient input and shared decision-making strategies. [West J Emerg Med. 2017;18(3)474-478.

Pijn op de borst : Veilige diagnose met de HEART-score

Doel Het meten van het effect van het gebruik van de HEART-score op patiëntuitkomsten en zorggebruik. Opzet ‘Stepped wedge’, cluster-gerandomiseerde trial. Methode In 9 Nederlandse ziekenhuizen includeerden we patiënten die zich in de periode juli 2013- augustus 2014 met pijn op de borst meldden op de Spoedeisende Hulp (SEH). Alle ziekenhuizen begonnen met een controleperiode en elke 6 weken stapte 1 willekeurig gekozen ziekenhuis over op de interventieperiode, de zogenoemde ‘HEART-care’. Tijdens HEART-care rekenden artsen de HEART-score van de patiënt uit om het verdere beleid te bepalen. Om de veiligheid van deze toepassing te evalueren, was er een non-inferiority-limiet van 3% absolute toename van cardiale gebeurtenissen binnen 6 weken na bezoek aan de SEH. Andere uitkomstmaten waren zorggebruik, kwaliteit van leven en kosteneffectiviteit (trialregistratie: ClinicalTrials.gov 80-82310-97-12154). Resultaten We includeerden 3648 patiënten (1827 in de controleperiode en 1821 in de interventieperiode). De incidentie van cardiale gebeurtenissen binnen 6 weken was in de interventieperiode 1,3% lager dan tijdens de controleperiode (bovenste limiet 95%-BI: 2,1%; de non-inferiority-limiet van 3% werd niet overschreden). Bij patiënten met een lage HEART-score was de incidentie van cardiale gebeurtenissen 2,0% (95%-BI: 1,2-3,3). We vonden geen significante verschillen in vroeg ontslag vanaf de SEH, heropnames, herhaalde bezoeken aan de SEH, poliklinische bezoeken of bezoeken aan de huisarts. Conclusie Het gebruik van de HEART-score voor de beoordeling van patiënten met pijn op de borst op de SEH is veilig, maar het effect op zorggebruik was gering, mogelijk door terughoudendheid van artsen om het voorgestelde beleid te volgen