Salim Rezaie, MD
Emergency Medicine/Internal Medicine Trained
Associate Clinical Professor at University of Texas Health Science Center
San Antonio, TX
Twitter @srrezaie
Matt Astin MD, MPH
Emergency Medicine/Internal Medicine Trained
Mercer University School of Medicine
Macon, GA
Twitter: @mastinmd
Anand Swaminathan, MD, MPH
Assistant Residency Director of Emergency Medicine at Bellevue/NYU
New York, NY
Twitter: @EMSwami
The HEART Score: A New ED Chest Pain
Risk Stratification Score
10Jan
January 10, 2014
Chest pain is a common presentation complaint to the emergency
department (ED) and has a wide range of etiologies including urgent diagnoses (i.e.
acute coronary syndrome (ACS), pulmonary embolism, aortic dissection) and nonurgent diagnoses (i.e. musculoskeletal pain, gastroesophageal reflux disease (GERD),
pericarditis). The challenge in the ED is to not only to identify high risk patients but also
to identify patients who can be safely discharged home. Specifically, when dealing with
ACS, dynamic ECG changes or positive cardiac biomarkers is pretty much a slam dunk
admission in most cases, but a lack of these does not completely rule out ACS.
Currently, most guidelines and risk stratification scores focus on the identification of
high risk ACS patients that would benefit from early aggressive therapies, but what
about all the other chest pain patients that don’t have ACS… are they accounted for?
What are some of the scoring methods currently used? (Backus et al.
2011)*
Risk
Score
Year of Score
Publication Range
Risk
Score
Year of Score
Publication Range
Score Predicts
C-Statistic of
Original
Study
Score Predicts
C-Statistic of
Original
Study
1 - 18
0.84 (death)
Risk of Death or death/MI at 30 days after
and 0.67
admission
(death/MI)
0-7
Risk of all cause mortality, MI, and severe
recurrent ischemia requiring urgent
0.65
revascularization within 14 days after
admission
GRACE 2003
1 - 372
Risk of hospital death and post-discharge
0.83
death at 6 months
FRISC
0-7
Treatment effect of early invasive
strategies in ACS
PURSUIT 2000
TIMI
2000
2004
0.77 (death)
and 0.7
(death/MI)
Risk
Score
Year of Score
Publication Range
Score Predicts
C-Statistic of
Original
Study
Risk
Score
Year of Score
Publication Range
Score Predicts
C-Statistic of
Original
Study
HEART
2008
Prediction of combined endpoint of MI,
0 - 10 PCI, CABG or death within 6 weeks after 0.90
presentation
What is the applicability of each score to clinical practice in
the ED?




PURSUIT: Does not include troponin assays as part of score and the majority of
the score is dependent on patient age.
TIMI: Simple to use, but has a poor predictive power (i.e. c-statistic 0.65)
GRACE: Very complex to use and a large portion of the score is dependent on
the patient age. Also patients not divided into different risk groups
FRISC: Like TIMI, is simple to use but has a poor predictive power (i.e. c-statistic
0.70)
All of the above scores are well validated, but none of them emphasizes patient history
as part of the score, used in identification of ACS in the ED setting, and chest pain due
to causes other than ACS were not evaluated in these trials. In truth, clinical judgement
plays a huge role for physicians in the ED when evaluating chest pain patients, so
wouldn’t it make sense to have a risk score that follows this? Well, that is exactly what
the HEART score does!
What is the HEART Score (Original Study)? (Six, Backus, and J C Kelder
2008)*
Has the HEART score been validated against TIMI and GRACE scores
(Validation Study)? (Backus et al. 2013)*
What they did:


2,440 unselected, chest pain patients from 10 hospitals
Applied TIMI, GRACE, and HEART Scores
Primary endpoint:


Occurrence of major adverse cardiac events (MACE) at 6 weeks
MACE = AMI, PCI, CABG, and death
Results of validation study (Different than original study shown above):




Low HEART Score (0 -3) = 1.7% MACE Rate
Intermediate HEART Score (4 – 6) = 16.6% MACE Rate
High HEART Score (7 – 10) = 50.1% MACE Rate
C-statistic of HEART Score (0.83) > TIMI (0.75) > GRACE (0.70)
Limitations:






Study performed on patient population from the Netherlands
Observational study
Each ED had different cut-off values for positive troponins
45 patients lost to follow up
No comparison of Heart Score to clinical gestalt
Confidence interval was a bit wide when looking at the total study population (i.e.
2.2)
Conclusion: The HEART score provides a quick and reliable predictor of outcomes in
chest pain patients presenting to the ED.
Take Home Points


The Heart Score was developed in an ED setting in all patients with chest pain
and not just ACS patients.
A larger, prospective study with narrower confidence intervals in a US population
would be nice, but best current evidence is that the HEART score performs better
than TIMI and GRACE scores.
Bibliography
Backus, B E, A J Six, J C Kelder, M A R Bosschaert, E G Mast, A Mosterd, R F
Veldkamp, et al. 2013. A prospective validation of the HEART score for chest pain
patients at the emergency department. International journal of cardiology, no. 3 (March
7). doi:10.1016/j.ijcard.2013.01.255. http://www.ncbi.nlm.nih.gov/pubmed/23465250.
Backus, B E, A J Six, J H Kelder, W B Gibler, F L Moll, and P A Doevendans. 2011.
Risk scores for patients with chest pain: evaluation in the emergency department.
Current cardiology reviews, no. 1. doi:10.2174/157340311795677662.
http://www.ncbi.nlm.nih.gov/pubmed/22294968.
Six, A J, B E Backus, and J C Kelder. 2008. Chest pain in the emergency room: value of
the HEART score. Netherlands heart journal : monthly journal of the Netherlands
Society of Cardiology and the Netherlands Heart Foundation, no. 6.
http://www.ncbi.nlm.nih.gov/pubmed/18665203