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MDCalc Wars: HEART Score Vs. EDACS

Both HEART and EDACS are best utilized for identifying patients with suspected ACS who are at low risk for MACE. HEART Score is specifically designed for patients presenting with chest pain, whereas EDACS can be applied to a broader patient population with various symptoms suspicious for ACS, including those with chest pain. Both HEART Pathway and EDACS-ADP can be applied using high-sensitivity troponin, resulting in a decreased number of low risk patients and rate of MACE.

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 Are we Missing Acute MIs with Clinical Risk Scores?

Clinical gestalt remains the most useful tool for assessment of risk of ACS/AMI. The use of risk assessment tools should be regarded as just that, tools. Keep in mind the limitations of each as you are taking care of patients.

Articles of Interest

Amazing GRACE-1 How Sweet the Guidelines – Recurrent, Low Risk Chest Pain in the Emergency Department

“These guidelines outline and summarize the evidence and strength of GRACE recommendations regarding eight priority questions of interest to emergency clinicians, other healthcare professionals, patients, and policymakers with regard to the evaluation and management of patients with recurrent, low-risk chest pain seen in the ED. Direct evidence for the selected priority questions in this population is lacking, which highlights areas which will benefit from further robust prospective investigation in this specific population.”

Chest Pain Scores

Summary of the different scores to identify low risk patients.

GRACE Guidelines: A Pragmatic Approach to Recurrent Low-Risk Chest Pain

GRACE guidelines offer a pragmatic, evidence-based framework for shared-decision making in patients with recurrent low-risk chest pain.

HEART vs EDACS Scores on Predicting Major Events Among Patients With Suspected Acute Coronary Syndrome

This study concludes that HEART score has better sensitivity than EDACS in predicting MACE among suspected ACS patients at the cardiac ED.

New tool helps emergency medicine physicians provide more personalized care to patients with chest pain

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.

Risk Scores for Clinical Risk Stratification of Emergency Department Patients With Chest Pain but No Acute Myocardial Infarction: A Systematic Review

The HEART score with a cutoff value of 3 or less accurately identified the greatest number of patients at low risk of 30-day MACE. However, MACE risk among patients who have MI ruled out by means of high-sensitivity troponin testing is sufficiently low that clinical risk stratification or noninvasive testing may be of little additional value in identifying patients with coronary disease.

Rules Identify Which Chest Pain Patients Can Be Sent Home

Two newly derived and validated clinical prediction rules have the potential for identifying a low-risk cohort of chest pain patients who could safely be discharged from the emergency department without extensive diagnostic evaluation. The two different rules were both derived from prospective cohort studies of emergency department populations. One, presented at the annual meeting of the Society for Academic Emergency Medicine by Dr. Erik P. Hess of the Mayo Clinic, Rochester, Minn., enrolled 2,718 patients. The other, presented by Dr. Frank Scheuermeyer of the University of British Columbia, Vancouver, included 1,669 patients.

The Fast and the Furious: Low-Risk Chest Pain and the Rapid Rule-Out Protocol

The low-risk patient with chest pain can be a high-risk scenario for the emergency physician. Accelerated decision protocols have been designed to aid the emergency physician in decision-making with regards to assessment of these patients. The use of these ADPs can reduce cost, length of stay and risk of unnecessary testing in chest pain patients. It is important for all emergency physicians to be familiar with different ADPs, and to know their benefits and limitations.

Resources

HEART Pathway

Identifies emergency department patients with acute chest pain for early discharge.

EDACS (Emergency Department Assessment of Chest Pain Score}

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.

HEART Score

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.

Vancouver Chest Pain Rule

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).

TIMI Risk Score for STEMI

Estimates mortality in patients with STEMI.

TIMI Risk Score for UA/NSTEMI

Estimates mortality for patients with unstable angina and non-ST elevation MI.