scholarly journals Secondary analysis of frequency, circumstances and consequences of calculation errors of the HEART (history, ECG, age, risk factors and troponin) score at the emergency departments of nine hospitals in the Netherlands

BMJ Open ◽  
2017 ◽  
Vol 7 (10) ◽  
pp. e017259 ◽  
Author(s):  
Marten Ras ◽  
Johannes B Reitsma ◽  
Arno W Hoes ◽  
Alfred Jacob Six ◽  
Judith M Poldervaart
Keyword(s):  
Risk Factors ◽  
Chest Pain ◽  
Emergency Departments ◽  
Clinical Decision Making ◽  
Troponin T ◽  
Secondary Analysis ◽  
Daily Practice ◽  
Heart Score ◽  
Risk Categorisation ◽  
Made In

ObjectiveThe HEART score can accurately stratify the risk of major adverse cardiac events (MACE) in patients with chest pain. We investigated the frequency, circumstances and potential consequences of errors in its calculation.MethodsWe performed a secondary analysis of a stepped wedge trial of patients with chest pain presenting to nine Dutch emergency departments. We recalculated HEART scores for all patients by re-evaluating the elements age (A), risk factors (R) and troponin (T) and compared these new scores with those given by physicians in daily practice. We investigated which circumstances increased the probability of incorrect scoring and explored the potential consequences.ResultsThe HEART score was incorrectly scored in 266 out of 1752 patients (15.2%; 95% CI 13.5% to 16.9%). Most errors occurred in the R (‘Risk factors’) element (61%). Time of admission, and patient’s age or gender did not contribute to errors, but more errors were made in patients with higher scores. In 102 patients (5.8%, 95% CI 4.7% to 6.9%) the incorrect HEART score resulted in incorrect risk categorisation (too low or too high). Patients with an incorrectly calculated HEART score had a higher risk of MACE (OR 1.85; 95% CI 1.37 to 2.50), which was largely related to more errors being made in patients with higher HEART scores.ConclusionsOur results show that the HEART score was incorrectly calculated in 15% of patients, leading to inappropriate risk categorisation in 5.8% which may have led to suboptimal clinical decision-making and management. Actions should be taken to improve the score’s use in daily practice.

scholarly journals LO97: Validation of the HEART score in Canadian emergency department chest pain patients using a high-sensitivity troponin T assay

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S61-S62 ◽  
Author(s):  
J. Andruchow ◽  
A. McRae ◽  
T. Abedin ◽  
D. Wang ◽  
G. Innes ◽  
...  
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Troponin T ◽  
High Sensitivity ◽  
Low Risk ◽  
Moderate Risk ◽  
Heart Score ◽  
High Sensitivity Troponin ◽  
High Sensitivity Troponin T ◽  
Pain Patients

Introduction: The HEART score is a validated tool created to risk stratify emergency department (ED) chest pain patients using 5 simple criteria (History, ECG findings, Age, Risk factors, and Troponin). Several studies have demonstrated the superiority of HEART over other well known risk stratification tools in identifying low risk chest pain patients suitable for early discharge. All but one of these studies used conventional troponin assays, and most were conducted in European populations. This study aims to validate the HEART score using a high-sensitivity troponin T assay in a Canadian population. Methods: This prospective cohort study was conducted at a single urban tertiary centre and regional percutaneous coronary intervention site in Calgary, Alberta. Patients were eligible for enrolment if they presented to the ED with chest pain, were age 25-years or older and required biomarker testing to rule out AMI at the discretion of the attending emergency physician. Patients were excluded if they had clear acute ischemic ECG changes, new arrhythmia or renal failure requiring hemodialysis. Clinical data were recorded by the emergency physician at the time of enrolment and outcomes were obtained from administrative data. High-sensitivity troponin-T (Roche Elecsys hs-cTnT) results were obtained in all patients at presentation. The primary outcome was AMI within 30-days of ED visit, the secondary outcome was 30-day major adverse cardiac events (MACE). Results: A total of 984 ED patients with complete HEART scores were enrolled from August 2014 to September 2016. The 30-day incidence of AMI and MACE in the overall population was 3.3% and 20.6%, respectively. HEART scores were predictive of 30-day AMI incidence: low risk (0-3): 0.77% (95%CI 0.0-1.5%), moderate risk (4-6): 4.3% (95%CI 2.3-6.2%) and high risk (7-10): 12.2% (95%CI 5.5-19.0%). HEART scores also predicted 30-day MACE: low risk (0-3): 5.0% (95%CI 3.1-6.9%), moderate risk (4-6): 31.8% (95%CI 27.2-36.4%) and high-risk (7-10): 61.4% (95%CI 51.2-71.5%). More than half of patients, 522 (53.0%) could be identified as low risk based on the HEART score using a single troponin result. Conclusion: Using a single high-sensitivity troponin result collected at ED presentation, the HEART score can rapidly and effectively identify more than half of ED chest pain patients as low risk for 30-day AMI, but is less sensitive for 30-day MACE.

scholarly journals 5 Pilot of a Modified HEART Score and Serial High Sensitivity Troponin T Pathway to Reduce Chest Pain Observations

2017 ◽  
Vol 70 (4) ◽  
pp. S2-S3
Author(s):  
R.S. Engineer ◽  
B.W. Marshall ◽  
J.T. Milk ◽  
E.L. Simon ◽  
C.M. Smalley ◽  
...  
Keyword(s):  
Chest Pain ◽  
Troponin T ◽  
High Sensitivity ◽  
Heart Score ◽  
High Sensitivity Troponin ◽  
High Sensitivity Troponin T

scholarly journals Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score

2017 ◽  
Vol 7 (2) ◽  
pp. 102-110 ◽  
Author(s):  
Maycel Ishak ◽  
Danish Ali ◽  
Marion J Fokkert ◽  
Robbert J Slingerland ◽  
Rudolf T Tolsma ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Chest Pain ◽  
Troponin T ◽  
St Segment Elevation ◽  
Heart Score ◽  
St Segment ◽  
Highly Sensitive ◽  
Highly Sensitive Troponin ◽  
Pain Patients

Background: The first study of the FamouS Triage project investigates the feasibility of ruling out a myocardial infarction in pre-hospital chest pain patients without electrocardiographic ST-segment elevation by using the modified HEART score at the patient’s home, incorporating only a single highly sensitive troponin T measurement. Methods: A venous blood sample was drawn in the ambulance from 1127 consecutive chest pain patients for measurement of the pre-hospital highly sensitive troponin T levels, in order to establish a pre-hospital HEART score (i.e. the modified HEART score) and evaluate the possibility of triage at the patient’s home. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) i.e. acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or death within 30 days after initial presentation. Results: Two hundred and six patients (18%) developed a MACE during 30 days of follow-up. Thirty-six per cent of the patients ( n=403) had a low modified HEART score (0–3 points) and none of them developed a MACE during follow-up. Forty-four per cent of the patients ( n=494) had an intermediate modified HEART score (4–6 points) and 18% of them developed a MACE. Twenty per cent of the patients ( n=230) had a high modified HEART score (7–10 points) of which 52% developed a MACE during follow-up. Conclusion: It seems feasible to rule out a myocardial infarction at home in chest pain patients without ST-segment elevation by using the modified HEART score. TRIAL ID: NTR4205. Dutch Trial Register [ http://www.trialregister.nl ]: trial number 4205.

scholarly journals Abnormal hb-levels associate differently with type 1 and type 2 myocardial infarction in patients visiting the emergency department with chest pain

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
S Forsell ◽  
A Najeb ◽  
H Habel ◽  
T Jerberg ◽  
R Hofmann ◽  
...  
Keyword(s):  
Risk Factors ◽  
Myocardial Infarction ◽  
Emergency Department ◽  
Chest Pain ◽  
Multinomial Logistic Regression ◽  
Relative Risk Ratio ◽  
Heart Score ◽  
Increased Risk

Abstract Background Previous studies have found an association between myocardial infarction (MI) and abnormal haemoglobin (Hb) but it is unknown whether Hb-levels are associated with type 1 and type 2 MI in unselected patients with chest pain visiting the emergency department (ED). Purpose To investigate the association between abnormal Hb-levels and type 1 and type 2 MI in patientens visiting the ED with chest pain. Methods The study population comprised all consecutive patients visiting four urban ED:s for chest pain between 2013–2016 with available data on Hb. Clinical data from the ED visit were cross-referenced to compulsory national registries retrieving information on previous diagnoses and treatments to identify history of cardiovascular disease (defined as previous MI, stroke or peripheral vascular disease), hypertension, hyperlipidaemia and diabetes mellitus. Patients were categorized depending on the exposure (Hb-level) to anaemia, normal and polycythaemia. The primary outcome (type 1 and type 2 MI) was identified in the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART). Relative risk ratio (RRR) was calculated using multinomial logistic regression, with 95% confidence interval (CI) using no infarction as reference. The robust sandwich estimator was used to estimate standard errors. Adjustments were made for risk factors according to HEART-score. Results A total of 64 606 patient with chest pain were included with a mean (SD) age of 56 (19) years and 48% were women. Anaemia was present in 10 204 (15.8%) and polycythaemia in 1598 (2.5%). Overall, type 1 MI occurred in 2 296 patients and type 2 MI in 145. The risk for type 1 MI was higher in both anaemia (RRR 1.8, 95% CI 1.6–2.0) and polycythaemia (RRR 1.6, 95% CI 1.3–2.0) compared to normal Hb. For type 2 MI the risk was markedly higher for both low and high Hb compared to normal (RRR 4.0, 95% CI 2.8–5.6) and (RRR 3.0, 95% CI 1.4–6.9). Taking age, gender and risk factors into account, patients with anaemia had a lower risk (RRR 0.8, 95% CI 0.7–0.9) for type 1 MI compared to patients with normal Hb whereas patients with polycythaemia still had a higher risk (RRR 1.6, CI 1.2–2.0). For type 2 MI, the risk remained higher for both low (RRR 1.9, 95% CI 1.3–2.8) and high Hb (RRR 2.8, 95% CI 1.3–6.2) compared to normal. Conclusion Abnormal Hb-levels in chest pain patients in the ED were significantly associated with an increased risk of type 1 or type 2 MI, however when accounting for risk factors, in a differential pattern. These novel findings indicate that Hb-level may be important when assessing patients for MI symptoms in the ED, however, further investigations are needed to establish the definite predictive value. FUNDunding Acknowledgement Type of funding sources: None. Adjusted results type 1 and type 2 MI

scholarly journals Diagnostic accuracy of the HEART Pathway and EDACS-ADP when combined with a 0-hour/1-hour hs-cTnT protocol for assessment of acute chest pain patients

2021 ◽  
pp. emermed-2020-210833
Author(s):  
Tsvetelina Nilsson ◽  
Erik Johannesson ◽  
Jakob Lundager Forberg ◽  
Arash Mokhtari ◽  
Ulf Ekelund
Keyword(s):  
Chest Pain ◽  
Risk Stratification ◽  
Diagnostic Accuracy ◽  
Troponin T ◽  
Secondary Outcome ◽  
Index Visit ◽  
Heart Score ◽  
Coronary Syndrome ◽  
Pain Patients ◽  
Rule Out

Background/aimIn ED chest pain patients, a 0-hour/1-hour protocol based on high sensitivity cardiac troponin T (hs-cTnT) tests combined with clinical risk stratification in diagnosing acute coronary syndrome is recommended. Two of the most promising risk stratification tools are the History, ECG, Age, Risk Factors and Troponin (HEART) and Emergency Department Assessment of Chest Pain (EDAC) scores. Few studies have assessed the diagnostic accuracy of the 0-hour/1-hour hs-cTnT protocol when combined with HEART score, and none with EDACS. In ED chest pain patients, we aimed to evaluate the diagnostic accuracy of a 0-hour/1-hour hs-cTnT protocol combined the HEART Pathway, or the EDACS accelerated diagnostic pathway (EDACS-ADP).MethodsThis was a secondary analysis of data from a prospective observational study enrolling 1167 ED chest pain patients who visited the ED at Skåne University Hospital in Lund, Sweden in the period between February 2013 and April 2014. HEART and EDAC scores were assessed together with hs-cTnT at 0 and 1 hour and compared with HEART score alone. Sensitivity, specificity, negative predictive value (NPV) and likelihood ratios were evaluated. The primary outcome was major adverse cardiac events (MACE) including unstable angina within 30 days. The secondary outcome was index visit acute myocardial infarction (AMI).ResultsA total of 939 patients were included in the final analysis. When combined with 0-hour/1-hour hs-cTnT testing, the HEART Pathway and EDACS-ADP identified 49.8% and 49.6% of the patients for rule-out, with NPVs for 30-day MACE of 99.8% and 99.1%, compared with the HEART score alone that identified 53.4% of the patients for rule-out with NPV of 99.2%. The NPV for index visit AMI were 100%, 99.8% and 99.2%, respectively.ConclusionThe combination of the HEART Pathway or the EDACS-ADP with a 0-hour/1-hour hs-cTnT protocol allows safe and early rule-out in a large proportion of ED chest pain patients.

scholarly journals Usefulness of the HEART Score with High-Sensitivity Troponin T for the Evaluation of Patients with Chest Pain

2018 ◽  
Vol 86 (5) ◽  
pp. 317-321 ◽  
Author(s):  
Marcia M. Cortés ◽  
Florencia Lambardi ◽  
Paula Ariznavarreta ◽  
Silvana Resi ◽  
Rosina Arbucci ◽  
...  
Keyword(s):  
Chest Pain ◽  
Troponin T ◽  
High Sensitivity ◽  
Heart Score ◽  
High Sensitivity Troponin ◽  
High Sensitivity Troponin T

scholarly journals Combined Use of High-Sensitive Cardiac Troponin, Copeptin, and the Modified HEART Score for Rapid Evaluation of Chest Pain Patients

2018 ◽  
Vol 2018 ◽  
pp. 1-7 ◽  
Author(s):  
Beata Morawiec ◽  
Brygida Przywara-Chowaniec ◽  
Piotr Muzyk ◽  
Mariusz Opara ◽  
Lam Ho ◽  
...  
Keyword(s):  
Chest Pain ◽  
Risk Stratification ◽  
Cardiac Troponin ◽  
Clinical Performance ◽  
Troponin T ◽  
High Sensitivity ◽  
Short Term ◽  
St Segment Elevation ◽  
Heart Score ◽  
Rule Out

Background. Clinical short-term risk stratification is a recommended approach in patients with chest pain and possible acute myocardial infarction (AMI) to further improve high safety of biomarker-based rule-out algorithms. The study aim was to assess clinical performance of baseline concentrations of high-sensitivity cardiac troponin T (hs-TnT) and copeptin and the modified HEART score (mHS) in early presenters to the emergency department with chest pain. Methods. This cohort study included patients with chest pain with onset maximum of 6 h before admission and no persistent ST-segment elevation on electrocardiogram. hs-TnT, copeptin, and the mHS were assessed from admission data. The diagnostic and prognostic value for three baseline rule-out algorithms: (1) single hs-TnT < 14 ng/l, (2) hs-TnT < 14 ng/l/mHS ≤ 3, and (3) hs-TnT < 14 ng/l/mHS ≤ 3/copeptin < 17.4 pmol/l, was assessed with sensitivity and negative predictive value. Primary diagnostic endpoint was the diagnosis of AMI. Prognostic endpoint was death and/or AMI within 30 days. Results. Among 154 enrolled patients, 44 (29%) were classified as low-risk according to the mHS; AMI was diagnosed in 105 patients (68%). For ruling out AMI, the highest sensitivity and NPV from all studied algorithms were observed for hs-TnT/mHS/copeptin (100%, 95% CI 96.6–100, and 100%, 95% CI 75.3–100). At 30 days, the highest event-free survival was achieved in patients stratified with hs-TnT/mHS/copeptin algorithm (100%) with 100% (95% CI 75.3–100) NPV and 100% (95% CI 96.6–100) sensitivity. Conclusions. The combination of baseline hs-TnT, copeptin, and the mHS has an excellent sensitivity and NPV for short-term risk stratification. Such approach might improve the triage system in emergency departments and be a bridge for inclusion to serial blood sampling algorithms.

scholarly journals Identification of high-risk non-ST elevation myocardial infarction at presentation to emergency department. A prospective observational cohort study in North West England

BMJ Open ◽  
2020 ◽  
Vol 10 (6) ◽  
pp. e030128
Author(s):  
Aleem Khand ◽  
Freddy Frost ◽  
Ruth Grainger ◽  
Michael Fisher ◽  
Pei Chew ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Emergency Department ◽  
Chest Pain ◽  
High Risk ◽  
Troponin T ◽  
Invasive Coronary Angiography ◽  
Multivariate Logistic Regression Analysis ◽  
St Elevation Myocardial Infarction ◽  
Heart Score ◽  
St Elevation

ObjectivesEarly access to invasive coronary angiography and revascularisation for high-risk non-ST elevation myocardial infarction (NSTEMI) improves outcomes and is supported by current guidelines. We sought to determine the most effective criteria at presentation to emergency department (ED) to identify high-risk NSTEMI.SettingSecondary care centre northwest England with national follow-up.Participants1642 consecutive patients (median age 59, 52% male) presenting to ED with a primary symptom of chest pain in whom there is suspicion of NSTEMI.Primary and secondary measuresMultivariate logistic regression analysis for the prediction of all-cause death (primary) and major adverse cardiac event (MACE defined as all-cause death, unplanned coronary revascularisation and adjudicated NSTEMI (third universal definition)) (secondary measure) at 1 year.ResultsThe incidence of adjudicated NSTEMI was 10.7%, and 1-year mortality was 6.3%. Independent predictors for all-cause death at 1 year were Global Registry of Acute Coronary Events (GRACE) >140, age (per decade increase) and high-sensitive cardiac troponin T (hs-cTnT) >50 ng/L. hs-cTnT >50 ng/L was associated with adjudicated index presentation NSTEMI in the greatest proportion of patients (61.7%). When using MACE at 12 months, as opposed to all-cause death, as an end point History, ECG, Age, Risk factors and Troponin (HEART) score ≥7 was included in the multivariate model and had better prediction of index NSTEMI than GRACE>140. Combining hs-cTnT >50 ng/L and a second independent predictor identified both a high proportion of index NSTEMI and elevated risk of all-cause death at 1 year.Conclusionshs-cTnT >50 ng/L or HEART score ≥7 appear effective strategies to identify high-risk NSTEMI at presentation to emergency room with chest pain. Multicentre prospective studies enriched with early presenters, and with competitor high-sensitive and point-of-care troponins, are required to validate and extend these findings.Trial registration numberNCT02581540.

The HEART score with high-sensitive troponin T at presentation: ruling out patients with chest pain in the emergency room

2016 ◽  
Vol 12 (3) ◽  
pp. 357-364 ◽  
Author(s):  
Luca Santi ◽  
Gabriele Farina ◽  
Annagiulia Gramenzi ◽  
Franco Trevisani ◽  
Margherita Baccini ◽  
...  
Keyword(s):  
Chest Pain ◽  
Emergency Room ◽  
Troponin T ◽  
Heart Score ◽  
High Sensitive Troponin
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