HEART Score Safely Informs Chest Pain Decisions in ED

Marcia Frellick

April 24, 2017

Using the HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score is a safe way to make care decisions for emergency department patients with chest pain, a new noninferiority study has found.

However, even when patients have a HEART score that signals low risk, physicians are often hesitant to choose not to admit them, the authors write, and that may be contributing to low healthcare cost savings.

"Such barriers should be addressed for patient management to better adhere to directive use of the HEART score," Judith M. Poldervaart, MD, PhD, from the Julius Center for Health Sciences and Primary Care at University Medical Center in Utrecht, the Netherlands, and colleagues explain. Their findings were published online April 24 in the Annals of Internal Medicine.

To test the effect of the HEART score on patient outcomes and healthcare use, the researchers enrolled 3648 unselected patients who presented to nine emergency departments in the Netherlands with chest pain in 2013 and 2014.

The analysis included 1827 patients who received usual care and 1821 who received HEART care, meaning physicians calculated the HEART score to guide them on treatment and admission decisions.

All hospitals started with usual care, but every 6 weeks, one hospital was randomly chosen to switch to "HEART" care.

With usual care, physicians assessed for acute coronary syndrome using tools such as laboratory tests, electrocardiograms, physical exams, medical histories, radiography, guidelines, their own expertise, and risk scores other than HEART scores.

Physicians using HEART care used routine work-ups plus calculating the HEART score and linking it to recommendations for management. The authors note that unlike other risk calculators for chest pain, "the HEART score was developed on the basis of clinical experience alone."

Researchers demonstrated noninferiority, showing 1.3% lower incidence of the primary endpoint, major adverse cardiac events, in the HEART group at 6 weeks and a 1-sided 95% upper confidence limit of 2.1%, which was within the prespecified noninferiority window of 3.0%.

"No statistically significant differences in early discharge, readmissions, recurrent emergency department visits, outpatient visits, or visits to general practitioners were observed," the authors write.

The researchers also found no significant differences between subgroups — women, elderly, and patients with diabetes — in the HEART or usual care groups.

The authors note that only 20% of patients who come to the emergency department with chest pain need prompt hospital admission and treatment. The rest have conditions that are noncardiac and non–life threatening and can be treated on an outpatient basis.

Still, conservative decisions by physicians mean about two-thirds of patients are admitted and get additional tests.

Although absolute differences were small in the HEART or usual care groups, a cost–benefit analysis (including nonadherence) estimates HEART care could lead to €40 million savings (nearly $US 43 million) each year in the Netherlands, the researchers write.

A research grant was obtained from the Netherlands Organisation for Health Research and Development. The authors have disclosed no relevant financial relationships.

Ann Intern Med. Published online April 24, 2017. Article

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