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Observational Study
. 2021 Aug;78(2):231-241.
doi: 10.1016/j.annemergmed.2021.03.024. Epub 2021 Jun 18.

A Prospective Evaluation of Clinical HEART Score Agreement, Accuracy, and Adherence in Emergency Department Chest Pain Patients

William E Soares 3rd  1 , Alex Knee  2 , Seth R Gemme  3 , Ruth Hambrecht  4 , Stacy Dybas  5 , Kye E Poronsky  3 , Shelby C Mader  3 , Timothy J Mader  5
Affiliations
Observational Study

A Prospective Evaluation of Clinical HEART Score Agreement, Accuracy, and Adherence in Emergency Department Chest Pain Patients

William E Soares 3rd et al. Ann Emerg Med. 2021 Aug.

Abstract

Study objective: The HEART score is a risk stratification aid that may safely reduce chest pain admissions for emergency department patients. However, differences in interpretation of subjective components potentially alters the performance of the score. We compared agreement between HEART scores determined during clinical practice with research-generated scores and estimated their accuracy in predicting 30-day major adverse cardiac events.

Methods: We prospectively enrolled adult ED patients with symptoms concerning for acute coronary syndrome at a single tertiary center. ED clinicians submitted their clinical HEART scores during the patient encounter. Researchers then independently interviewed patients to generate a research HEART score. Patients were followed by phone and chart review for major adverse cardiac events. Weighted kappa; unweighted Cohen's kappa; prevalence-adjusted, bias-adjusted kappa (PABAK); and test probabilities were calculated.

Results: From November 2016 to June 2019, 336 patients were enrolled, 261 (77.7%) were admitted, and 30 (8.9%) had major adverse cardiac events. Dichotomized HEART score agreement was 78% (kappa 0.48, 95% confidence interval [CI] 0.37 to 0.58; PABAK 0.57, 95% CI 0.48 to 0.65) with the lowest agreement in the history (72%; WK 0.14, 95% CI 0.06 to 0.22) and electrocardiogram (85%; WK 0.4, 95% CI 0.3 to 0.49) components. Compared with researchers, clinicians had 100% sensitivity (95% CI 88.4% to 100%) (versus 86.7%, 95% CI 69.3% to 96.2%) and 27.8% specificity (95% CI 22.8% to 33.2%) (versus 34.6%, 95% CI 29.3% to 40.3%) for major adverse cardiac events. Four participants with low research HEART scores had major adverse cardiac events.

Conclusion: 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.

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Conflict of interest statement

Conflicts of Interest: The authors have no financial conflicts or competing interests to disclose.

Figures

Figure 1.
Figure 1.
Emergency Department (ED) HEART score study design
Figure 2:
Figure 2:
Emergency Department (ED) HEART score enrollment flow diagram.
See this image and copyright information in PMC

References

    1. Owens PL, Barrett ML, Gibson TB, Andrews RM, Weinick RM, Mutter RL. Emergency department care in the United States: a profile of national data sources. Ann Emerg Med. 2010. August;56(2):150–65. - PubMed
    1. Weinstock MB, Weingart S, Orth F, VanFossen D, Kaide C, Anderson J, et al. Risk for Clinically Relevant Adverse Cardiac Events in Patients With Chest Pain at Hospital Admission. JAMA Intern Med. 2015. July 1;175(7):1207. - PubMed
    1. Lin GA, Redberg RF. Addressing Overuse of Medical Services One Decision at a Time. JAMA Intern Med. 2015. July 1;175(7):1092. - PubMed
    1. Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. NHJL. 2008. June;16(6):191–6. - PMC - PubMed
    1. Backus BE, Six AJ, Kelder JC, Mast TP, van den Akker F, Mast EG, et al. Chest Pain in the Emergency Room: A Multicenter Validation of the HEART Score. Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine. 2010. September;9(3):164–9. - PubMed

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