Presentation of the past and current evidence of the HEART score for chest pain patients at the Emergency Department

1. Six years of HEART score
BE Backus, MD, PhD
Medical Center The Hague, Netherlands
Resident Emergency Medicine

3. How it began
• Risk score for chest pain patients
• 5 elements
• 0, 1 or 2 points
• Analogue to the APGAR score

4. How it began
HEART

5. How it began
HEART

6. How it began
HEART

7. How it began
HEART

8. How it began
HEART

9. History
(anamnesis)
Highly suspicious 2
Moderately suspicious 1
Slightly or non-suspicious 0
ECG Significant ST-deviation 2
Non specific rep disturbance / LBTB / PM 1
Normal 0
Age ≥ 65 year 2
45 – 65 year 1
≤ 45 year 0
Risk
factors
≥ 3 risk factors or history of (treated)
atherosclerosis
2
1 or 2 risk factors 1
No risk factors known 0
Troponin ≥ 3x normal limit 2
1-3x normal limit 1
≤ normal limit 0
Total
HEART score for chest pain patients

12. N=120

13. C-stats 0.90
NPV 97.5%

14. Validation program of HEART

15. Accurate
Compare

16. Regression
analysis
Troponin
Exercise
testing
Medical
Consumption
Medical
Consumption
Single
Site
Retro
NL
Prospective
NL Prospective
Pacific
Implement
HEART
Pooled Results
Elderly
Diabetics
Women
TIMI
TIMI
GRACE

17. All
MACE
Death/
AMI
ACS p value
HEART vs
HEART 0.83 0.82 0.86
TIMI 0.75 0.70 0.78 < 0.0001
GRACE 0.70 0.71 0.72 < 0.0001
Discriminative performance (n=2388)
HEART-TIMI-GRACE

18. Graphic results of three risk scores (n=2388)
0
10
20
30
40
50
60
70
80
PercentageMACE
From minimum to maximum score
HEART
TIMI
GRACE

19. Risk groups and proposed policy when using the
HEART score (pooled results n=6174)
HEART ~ % pts MACE/n MACE Death
Proposed
Policy
0-3 32% 38/1993 1.9% 0.05% Discharge
4-6 51% 413/3136 13% 1.3%
Observation,
risk
management
7-10 17% 518/1045 50% 2.8%
Observation,
treatment, CAG
www.heartscore.nl

20. MACE risk per HEART score (n=6174)
HEART ≤ 1
0.8%
6.5% pts
HEART ≤ 2
1.1%
11.4%
HEART ≤ 3
1.9%
32.3%
HEART ≤ 4
3.7%
51.1%

21. So HEART works, and then?
EFFICIENCY
PATIENT BENEFIT
COST SAVING
TROPONINS
DIAGNOSTICS

22. ESC guidelines N-STEMI 2015

23. ESC guidelines N-STEMI 2015

24. GRACE won’t help the EP
HEART will !

26. HEART regression analysis
HEART HEART-adj
H
0
1
2
0
3
4
E
0
1
2
0
1
2
A
0
1
2
0
2
2
R
0
1
2
0
1
1
T
0
1
2
0
2
5
Max 10 14
c-stats 0.832 0.851
Submitted

27. Higher calibration
NRI 14.1%
in favour of original HEART!

29. Single high sensitive troponin
EW Carlton et al

30. HEART + hs troponin T or I
Hs Troponin I Hs Troponin T
Endpoint: AMI < 30 days

33. Study protocol

34. HEART-Impact trial: stepped wedge

35. HEART impact trial
3666 inclusions
1833 HEART intervention
3 % no HEART score
1833 Usual Care
1821 HEART intervention1827 Usual Care
18 patients FU - / drop out

36. Impact limited
By non-adherence to protocol
2.0%
SAFE

37. Mahler, Crit Card Qual Outc, 2015 (8), 195-203

38. HEART Pathway study
• 282 patients with 141 patients in each arm of the study
• HEART Pathway identified of 46.8% of patients as low risk
• Zero patients identified as low risk had a MACE
0
10
20
30
40
50
60
70
80
discharge HEART
discharge UC
testing HEART
testing UC
LOS HEART
LOS UC
39.7% 18.4% 56.7% 68.8% 9.9 hr 21.9 hr

42. HEART score is safe to use
in chest pain patients
Please follow your HEART…

43. www.heartscore.nl
@barbrabackus