Many patients presenting with chest pain undergo unnecessarily extensive and costly evaluations to rule out ACS. The HEART Pathway can reduce the number of prolonged and invasive evaluations, while maintaining high sensitivity and negative predictive value for ACS. Unlike other scoring systems such as the TIMI Risk Index or the GRACE Risk Score, the HEART Pathway is designed to predict the likelihood of ACS in the patient presenting to the ED with acute chest pain. TIMI and GRACE scores are used to risk stratify patients who have been diagnosed with ACS.
The HEART score has been widely adopted by emergency physicians since its publication in 2008. EPs seem to like it and use it appropriately. Some ED staffing companies even recommend or require its use. Even some of my hospitalists know it, but, unfortunately, they seem to use it primarily to block admissions by giving patients a lower score than I do or to deny the possibility of unstable angina.
The HEART score doesn't have the best interrater reliability. This is typically based on the interpretation of the history or the ECG. This scoring difference obviously becomes important when one physician gives a 3 and the other a 4, leading to disagreement on risk for 30-day major adverse cardiac events (MACE) and final disposition.
Identifies emergency department patients with acute chest pain for early discharge.
Identifies chest pain patients with low risk of major adverse cardiac event. This score only applies to patients: (1) ≥18 years old with normal vital signs; (2) Chest pain consistent with ACS; (3) No ongoing chest pain or crescendo angina.
Predicts 6-week risk of major adverse cardiac event. Use in patients ≥21 years old presenting with symptoms suggestive of ACS. Do not use if new ST-segment elevation ≥1 mm or other new EKG changes, hypotension, life expectancy less than 1 year, or noncardiac medical/surgical/psychiatric illness determined by the provider to require admission.
Estimates mortality in patients with STEMI.
Estimates mortality for patients with unstable angina and non-ST elevation MI.
In conclusion, the modified HEART risk score was validated in chest pain patients with suspected NSTE-ACS and may complement MACE risk assessment and patients triage in the ED. A prospective study of the score is warranted.
The HEART score is an easy, quick and reliable predictor of outcome in chest pain patients and can therefore be used for triage.
The goal of these rules is to identify a low-risk
population of patients who need less testing
than other, higher-risk patients. As a rule-out
calculator, the EDACS is good at identifying
who is relatively safe to go home (highly sensitive), but not good at identifying who does
have the disease (not terribly specific).
The study found that both the RISTRA-ACS and the HEART pathway risk scores accurately identified very low-risk patients. However, the RISTRA-ACS risk score was found to be better than the HEART score, troponin tests alone, and physician judgement in distinguishing which patients would experience a major heart problem within 60 days. In addition, the RISTRA-ACS tool accurately risk stratified more than 50% of the patients with only a single troponin measurement, whereas the EDACS-ADP and HEART pathway require multiple troponin tests.
The HEART score has been validated in several studies and has proven to be a powerful, easy, and above all practical instrument to separate patients into a low, medium and high risk groups. Patients scoring 0-3 have a 1.6% chance of experiencing a cardiac event, those with a score 4-6 have a 13% chance, and those scoring 7 or higher have a 50% chance of developing a myocardial infarction, PTCA, CABG or death within 6 weeks following presentation.
ED clinicians had only moderate agreement with research HEART scores. Combined with uncertainties regarding accuracy in predicting major adverse cardiac events, we urge caution in the widespread use of the HEART score as the sole determinant of ED disposition.
The TIMI Risk Score for UA/NSTEMI can be used
to help risk stratify patients with presumed ischemic chest pain. However, it was originally derived in patients with confirmed unstable angina
or non-ST elevation myocardial infarction.
e. The Vancouver
Chest Pain Rule identifies low-risk chest pain
patients who can be safely discharged from the
ED after the standard initial evaluation of history
and physical examination, ECG, and 1 cardiac
biomarker (usual-sensitivity troponin).
The HEART Pathway identifies patients who are
safe for early discharge versus those who need
observation, admission, and potentially emergent cardiology assessment.
• While patients with ischemic changes on electrocardiogram (ECG) or elevated troponin may
be classified as low-risk using the HEART Pathway, the creators recommend again.