A prospective evaluation of clinical HEART score agreement, accuracy, and adherence in emergency department chest pain patients

1. A prospective observational study demonstrated moderate agreement between clinicians and researchers in assigning patients a HEART score.

Evidence Rating Level: 2 (Good)

The HEART score is a risk stratification aid used frequently in emergency departments (ED) to estimate the probability of major adverse cardiac events within 30 days for patients with symptoms concerning for acute coronary syndrome. Although validation studies on this tool have been conducted, there is limited research to demonstrate the utility of the HEART score when used by a clinician outside research settings. This prospective study aimed to evaluate the agreement between HEART scores calculated during practice (clinician scores) and scores generated using standardized research methods (research scores) as well as determine the accuracy of these scores in predicting 30-day adverse cardiac events. The study included 336 participants (53% men; median age, 59 years), many with multiple comorbidities such as hypertension, dyslipidemia, and diabetes mellitus. The primary outcome measured was agreement between clinician and research dichotomous HEART scores, defined as low-risk (0 to 3) versus moderate-to-high risk (4 to 15). Dichotomous HEART score agreement between clinicians and researchers was 78% (n=263). 49 patients scored by clinicians to be moderate-to-high risk had low-risk researcher scores and 24 patients scored as low risk by clinicians had moderate-to-high risk researcher scores. In terms of the components of the score, agreement was highest for age (96.7%) and troponins (98%). It was lowest for history (72%), with clinicians assigning a higher mean history score. There were 73 discordant scores, of which 59% (n=43) varied by 1 point, 37% (n=27) varied by 2 points and 4% (n=3) varied by 3 points. History, risk factors, and ECG interpretations had the highest rates of disagreements in discordant scores (44.7%, 32.5%, and 19.3%, respectively). Compared to research-generated HEART scores, ED clinicians’ HEART scores demonstrated higher sensitivity (100%; 95% CI, 88.4%-100% versus 86.7%; 95% CI 69.3%-96.2%) and lower specificity (27.8%; 95% CI 22.8%-33.2% versus 34.6%; 95% CI 29.3%-40.3%) in predicting 30-day major adverse cardiac events. Although this was a smaller single-centered study, it helped shed light on disagreements between clinician HEART scores and those calculated by researchers. In culmination, study findings provide insight into the limitations of utilizing HEART scores as the sole determinant of patient disposition.

Click to read the study in Annals of Emergency Medicine

Image: PD

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