HEAR SCORE: A Proposal to Use Only Anamnestic and EKG Data to Evaluate Patients with Very Low Risk Chest Pain

Abstract

Purpose

Chest pain in a common symptom in patients attending Emergency Department worldwide and can be related to an extensive variety of disorders, so it represents a diagnostic and logistic challenge for Emergency physicians. The aim of this study is to identify a subgroup of patients with a low pre-test probability of major adverse cardiac events, for which there is no need of troponin testing, to avoid potential harm from false-positive testing and long length stay in ED.

Patients and Methods

We retrospectively analyzed data of patients that attended ED of Siena complaining chest pain from January 2019 to August 2021. We used a modified HEART score, only evaluating history, EKG, age and risk factors. A 0–1 HEAR score was considered at very low risk for adverse cardiac events. Sensitivity, specificity, PPV, NPV and incidence of adverse cardiac events were calculated. The accuracy of HEAR score was evaluated with ROC curve. The correlation of adverse cardiac events with HEAR score 0–1 was evaluated with Fisher test.

Results

In this study, we included 2046 patients, of which 279 were classified at very low risk. The incidence of adverse cardiac events in this population was 0.36%. Sensibility was 97.5%, sensitivity 61%, PPV 36.8%, NPV 99.1%. The AUC for global accuracy of HEAR score was 0.945. Chi-square’s P value for the association between adverse cardiac events and HEAR score 0–1 was <0.001.

Conclusion

The draft presented in this study answers to the necessity to make a personalized path for patients attending ED with chest pain. The choice to avoid troponin testing may appear risky, but data from this study and from other similar show that a careful evaluation of clinical data and EKG allows to correctly discriminate which patients will not have adverse cardiac events, reducing the length of stay in ED.

Keywords:

• chest pain
• HEAR score
• emergency medicine
• troponin
• electrocardiogram

Abbreviations

ACS, Acute Coronary Syndrome; AOUS, Azienda Ospedaliera Universitaria Senese; CAD, Coronary Artery Disease; ED, Emergency Department; EKG, Electrocardiogram; HEAR, History, ECG, Age, Risk factors; MACE, major adverse cardiac events; NPV, negative predictive value; PPV, positive predictive value.

Ethics Approval and Consent to Participate

Ethics approval was acquired by the Hospital Healthcare Management of the AOUS. We were allowed from the dataset owner to use the information in databases for the purposes of the research. The present study did not involve the use of confidential or sensitive personal health information therefore the patient consent was not required. The study was conducted in compliance with the Helsinki Declaration of 975, as revised in October 2013 and all data were kept anonymous.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare that they have no conflicts of interest in this work.