Safety of evaluating for acute coronary syndrome in the emergency department using a modified heart score
Do A, Radjef R, Aurora L, Singh A, Tawney A, Kraus D, Jacobsen G, and McCord J. Safety of evaluating for acute coronary syndrome in the emergency department using a modified heart score. Journal of the American College of Cardiology 2020; 75(11):127.
J Am Coll Cardiol
Background Chest pain is a common complaint in the emergency department (ED). The evaluation of these patients, which commonly involves stress testing, is time-consuming and costly. Prior retrospective studies demonstrated that a modified HEART score (m-HS) which combines the traditional HS and serial high-sensitivity cardiac troponin measurements could be used to identify low risk patients for discharge from the ED without further cardiac testing. The HS combines elements of the history, cardiac risk factors, and ECG. A HS ≤ 3 is considered low risk. In this study, we evaluated the safety of implementing this concept prospectively. Methods A prospective implementation trial conducted at an ED in 2017 included adult patients who were evaluated for possible acute coronary syndrome. Patients needed to have Siemens cardiac troponin I ultra < 40 ng/L (99th%) at 0 and 3 hours in addition to a HS ≤ 3 to be discharged without further testing. Thirty-day major adverse cardiovascular events (MACE) (death, acute myocardial infarction, revascularization procedure and readmission) were recorded. Results Of 422 patients, 33 were lost to follow up, resulting in 389 for analysis. The mean age was 50.6 ± 14.4. There were 161 (41.6%) male, 203 white (52.6%), 135 (35%) black and 48 (12.4%) classified as others. Baseline risk factors: 128 (33%) hypertension, 35 (9.1%) diabetes, 100 (25.8%) hyperlipidemia, 14 (3.6%) coronary artery disease, 98 (25.5%) active smoker, 25 (6.5%) with family history of cardiac disease. Among the 3 MACEs (0.8%) which were all 30-day readmissions, 2 (0.5%) were non-cardiac related while 1 (0.3%) was for atypical chest pain that was determined to be non-cardiac chest pain by cardiology consultation. This patient also had the only positive cardiac test (1.8%) (myocardial perfusion imaging with minimal ischemia) out of the 56 outpatient cardiac stress tests. Conclusion In the ED setting, m-HS is an effective tool to identify low risk patients who are safe for early discharge. At 30 days, no significant MACEs were detected and these low risk patients likely do not require stress testing.