163 Outcome of integration of new centaur (Siemen’s) high-sensitivity troponin I assay with heart score chest pain pathway to maximise early discharge from Emergency Department (ED)

Introduction Chest pain is a common presentation to the emergency department (ED). Differentiating those with an Acute Coronary Syndrome from the majority without, within 4 hours, is a priority. Introduction of high-sensitivity TnI assays has the potential to allow early discharge from ED but at the expense of lower specificity. Given the pressure in ED to identify patients who can safely be discharged we developed an algorithm based on the HEART score. This combines the history, ECG, age, risk factors and hsTnI level and outperforms TIMI and GRACE scores in identifying low-risk patients. Patients with a score of ≥4 have an increased major adverse cardiac event (MACE) rate at 30 days; those with a score of <4 are suitable for early discharge. There are no studies utilising the CENTAUR assay combined with a clinical risk score. Methods An initial algorithm based on the HEART score tool was developed incorporating estimated hsTnI boundaries for the CENTAUR assay to inform the “T” component of the tool. This was tested on a 2 month sample of patients presenting with chest pain to the ED. Following review a revised pathway was developed. Patient outcome was recorded with both pathways including subsequent investigations and MACE at 30 days and compared with historical discharge rates for chest pain from the same ED. Sensitivity, specificity and NPV were calculated. Results There were 478 presentations with chest pain and at least one hsTnI level. Age ranged from 13 to 98 years (median 56); 50% were male. There were 21 (4%) MACE within 30 days of the initial presentation (NSTEMI: 18, STEMI: 1, unstable angina requiring CABG: 1, acute pulmonary oedema: 1). A 2 hour hsTnI ≤8 identified a low-risk group with no MACE <30 days. 30% of patients using the initial pathway had a HEART score of ≥4 (100% sens, 73% spec). 70% were suitable for ED discharge; there were no MACE in this group (100% NPV). A revised pathway was derived incorporating previous cardiac history and modified hsTnI boundaries. Applying this to the original cohort would have increased the proportion suitable for ED discharge to 82%. Both pathways improved the proportion of patients who could be discharged directly from ED from a historical 64%. The revised pathway demonstrated improved specificity for the identification of MACE with no loss of sensitivity and excellent negative predictive value. (100% sens, 86% spec, 100% NPV). Conclusions The CENTAUR hs-TnI assay and HEART score with modifications would facilitate the early discharge of patients with chest pain from ED within 4 hours without missing any MACE at 30 days. This conclusion should be validated in a prospective cohort.

CAN PATIENTS PRESENTING TO THE ED WITH CHEST PAIN WHO HAVE INTERMEDIATE-RISK HEART SCORES BE MANAGED AS OUTPATIENTS? A RETROSPECTIVE REVIEW OF TWO RAPID ACCESS CHEST PAIN CLINICS

Several scoring systems have been proposed to predict the outcomes of patients with ischemic heart disease. Global Registry of Acute Coronary Events (GRACE) and History, ECG, Age, Risk Factors, and Troponin (HEART) scores are two of the more widely used risk prediction tools in patients with acute coronary syndrome (ACS). The present systematic review and meta-analysis aimed to compare the value of GRACE and HEART scores in the outcome prediction of ACS patient. The online databases of Medline, Embase, Web of Science, and Scopus were search until September 2022 for articles directly comparing GRACE and HEART scores value in prediction of outcome in patients with ACS. GRACE score cut-offs were categorized into two groups of less than and equal to 100 and more than 100, and HEART score cut-offs were categorized into three groups of less than 4, equal to 4, and more than 4. Investigated outcomes were major adverse cardiovascular events (MACE), acute myocardial infraction (AMI) and all-cause mortality. 25 articles were included. The sensitivity and specificity of the GRACE score for prediction of MACE were 0.96 and 0.26 for cut-offs of ≤ 100, and 0.58 and 0.69 for cut-offs of >100, respectively. The sensitivity and specificity of the HEART score for prediction of MACE were 0.99 and 0.16 for cut-offs less than 4, 0.93 and 0.47 for equal to 4, and 0.77 and 0.78 for cut-offs greater than 4. GRACE score was shown to be predictive of AMI with sensitivity and specificity of 0.95 and 0.29, respectively. The analysis for the value of HEART score in the prediction of AMI a sensitivity and specificity of 0.94 and 0.48, respectively. The risk scores were not found to be suitable predictors of all-cause mortality. The results demonstrated the low specificity of GRACE and HEART scores in predicting the MACE, AMI and all-cause mortality, irrespective of the utilized cut-off. Considering the acceptable sensitivity of two scores in predicting the MACE and AMI, these scores were more suitable to be used as a rule-out tool for identification of ACS patients with low risk of developing adverse outcomes.

The history, electrocardiogram, age, risk factors, troponin (HEART) and global registry of acute coronary events (GRACE) scoring systems are commonly used to risk stratify patients with chest pain. This study investigated the application of these scores in predicting the short-term risk of a major adverse cardiac event (MACE) in patients with chest. A total of 509 patients were analyzed. All patients were followed up for 30days after visiting our emergency department. At 30days post-admission, the primary outcome (MACE) was recorded in 92 patients (18.1%), 88 (95.6%) of whom had experienced an acute myocardial infarction. Thirty-seven (40.2%) of the patients with a MACE underwent percutaneous coronary intervention and six patients (6.5%) died. The HEART and GRACE scores were both significantly higher in patients who developed a MACE than in those without (P < 0.05). The HEART and GRACE scores had c-statistic values of 0.811 (95% CI 0.774-0.844) and 0.648 (95% CI 0.603-0.688), respectively. The Hosmer-Lemeshow statistic revealed that the HEART and GRACE scores had values of 8.68 (P = 0.39) and 10.45 (P = 0.11), respectively. The percentages of patients with HEART scores of 0-3, 4-6, and 7-10 were 3.0%, 26.2%, and 46.3%, respectively, in those with a MACE within 30days. The findings show that while both scoring systems are useful, the HEART score is superior to the GRACE score for predicting the occurrence of MACE within 30days in patients with chest pain.

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In Reply.

Acute coronary syndromes (ACS) are hard to diagnose because their clinical presentation is broad. Current guidelines suggest early clinical risk stratification to the optimal site of care. The aim of this study was to investigate the ability of Thrombolysis in Myocardial Infarction (TIMI); History, Electrocardiogram, Age, Risk Factors, Troponin (HEART); and Global Registry of Acute Coronary Events (GRACE) risk scores to predict the development of major adverse cardiac events (MACE) and the angiographic severity of coronary artery disease (CAD) in patients diagnosed with non-ST-segment elevation acute coronary syndrome (NSTEACS) in the emergency department (ED). In addition, independent variables associated with the development of MACE were also examined. This study is a prospective, observational, single-center study. All patients over 18 years of age who were planned to be hospitalized for pre-diagnosed NSTEACS (NSTEMI + UAP) were included in the study consecutively. Patients' demographic information and all variables necessary for calculating risk scores (TIMI, HEART, and GRACE) were recorded. Two experienced cardiologists evaluated all coronary angiograms and calculated the Gensini score. The median age was 60 (IQR: 18) years, and 220 (61.6%) were male of the 357 patients included in the study. In this study, 91 MACE (52 percutaneous coronary interventions [PCI], 28 coronary artery bypass graft [CABG], three cerebrovascular disease [CVD], and eight deaths) occurred. The 30-day MACE rate was 25.5%. The low-risk group constituted 40.0%, 1.4%, and 68.0% of the population, respectively, in TIMI, HEART, and GRACE scores. Multiple logistic regression models for predicting MACE, age (P = .005), mean arterial pressure (MAP; P = .015), and High-Sensitive Troponin I (P = .004) were statistically significant. The ability of the GRACE, HEART, and TIMI risk scores to predict severe CAD in patients with NSTEACS is similar. In patients with NSTEACS, the HEART and GRACE risk scores can better predict the development of MACE than the TIMI risk score. When low-risk groups are evaluated according to the three risk scores, the HEART score is more reliable to exclude the diagnosis of NSTEACS.

Objective: Age, Risk factors, and Troponin (HEART), Thrombolysis in Myocardial Infarction (TIMI), and Score, and Global Registry of Acute Coronary (GRACE) Scores are critical for identifying patients at risk for major adverse cardiac events (MACE), guiding timely interventions, and optimizing resource utilization.This study aimed to evaluate the comparative utility of these three scoring systems in predicting MACE in patients visiting the emergency department (ED). Materials and Methods:This prospective observational study included 502 adult patients visiting the ED with chest pain of a tertiary hospital between December 2014 and March 2015.HEART Score, TIMI, GRACE Score were evaluated for MACE over a 14-day and six-week, period.Data collected included demographic characteristics, clinical findings, laboratory results, and outcomes such as myocardial infarction, coronary angiography, revascularization, and mortality.Statistical significance was set at p<0.05.Results: At 14-day follow-up, the HEART Score identified 192 patients as "low risk", of which 2.5% missed MACE.The GRACE Score identified 276 patients as "low risk", of which 10.5% missed MACE.The TIMI Score identified 288 patients as "low risk", of which 12.8% missed MACE.The area under the curve (AUC) for HEART Score, TIMI Score, and GRACE Score for 14-day MACE was calculated as 0.767, 0.678, and 0.674.In addition, the AUC for HEART Score, TIMI Score, and GRACE Score for MACE at 6-week follow-up was calculated as 0.700, 0.649 and 0.704. Conclusion:The HEART Score demonstrates higher prognostic value for predicting MACE within 14 days than the TIMI and GRACE Scores in patients visiting the ED with chest pain.The TIMI Score has lower prognostic value for predicting MACE over a 6-week period compared to the HEART and GRACE Scores.

ResumoFundamento Múltiplos sistemas de pontuação têm sido elaborados para calcular o risco de eventos cardiovasculares adversos maiores (MACE) em pacientes com dor no peito. Não há dados que avaliem se o escore HEART tem um desempenho superior a TIMI e GRACE para a predição de MACE, especialmente na era de troponina I de alta sensibilidade e em uma população exclusivamente latino-americana.Objetivo Comparar o desempenho dos escores HEART, TIMI e GRACE para a predição de MACE em 30 dias de acompanhamento, em pacientes atendidos com dor no peito no departamento de emergência.Métodos Os escores HEART, TIMI e GRACE foram analisados em 519 pacientes com dor no peito no departamento de emergência. O desfecho primário foi a ocorrência de MACE no período de 30 dias. O desempenho do escore HEART foi comparado com o dos escores TIMI e GRACE utilizando o teste de DeLong, considerando estatisticamente significativos os valores de p de 0,05.Resultados Um total de 224 pacientes (43%) apresentaram MACE no período de 30 dias. A estatística C para os escores HEART, TIMI e GRACE foi de 0,937, 0,844 e 0,797 respectivamente (p < 0,0001). Uma pontuação de 3 ou menos no escore HEART apresentou uma sensibilidade de 99,5% e um valor preditivo negativo de 99% para classificar pacientes de baixo risco de maneira correta; ambos os valores foram mais elevados do que aqueles obtidos pelos outros escores.Conclusão O escore HEART, em um período de 30 dias, prediz eventos cardiovasculares, mais eficazmente, em comparação com os outros escores. Troponinas de alta sensibilidade mantêm a superioridade previamente demonstrada deste escore. Este escore oferece uma identificação mais precisa dos pacientes de baixo risco. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Comparing HEART, TIMI, and GRACE scores for prediction of 30-day major adverse cardiac events in high acuity chest pain patients in the emergency department

ObjectiveThe history, electrocardiogram, age, risk factors, troponin (HEART), the thrombolysis in myocardial infarction (TIMI), and Global Registry of Acute Coronary Events (GRACE) scores are useful risk stratification tools in the emergency department (ED). However, the accuracy of these scores in the cancer population is not well known. This study aimed to compare the performance of cardiac risk stratification scores in cancer patients with suspected acute coronary syndrome (ACS) in the ED.MethodsThis prospective cohort study recruited patients with cancer who visited the ED because of suspected ACS. The development of any major adverse cardiac events (MACE) within 6 weeks was recorded, with the study outcome being a MACE within 6 weeks of ED admission.ResultsA total of 178 patients participated in this study, of whom 5.6% developed a MACE. Statistically significant differences were found between the mean HEART and TIMI scores in predicting MACE. The HEART score had the highest area under the curve (0.64; 95% confidence interval, 0.48–0.81), highest sensitivity (80%), and highest negative predictive value (97.5) in patients with cancer.ConclusionWe found a similar rate of MACE in cancer patients with low-risk chest pain compared to that in the general population. However, the HEART, TIMI, and GRACE scores had a lower performance in cancer patients with MACE compared to that in the general population.

BackgroundA significant number of chest pain patients had previous cardiac imaging tests (CIT) performed before being presented to the Emergency Department (ED). The HEART (history, electrocardiogram, age, risk factors, and troponin) score has been used to risk-stratify chest pain patients in the ED, but not particularly for patients with CIT performed. We aim to modify the current HEART score with the addition of most recent CIT findings (referred to as HEART2 score), to predict a 30-day major adverse cardiac event (MACE) among ED chest pain patients, compare the performance accuracy of using HEART versus HEART2 score for 30-day MACE outcome predictions, and further determine the value of HEART2 in a subset group of ED chest pain patients (i.e., ones with previous CIT).MethodsThis is a single-center observational study. We included chest pain patients with HEART scores calculated during their index ED visits. A modified HEART2 score was developed with the addition of CIT findings as one of the HEART2 components. Patients were divided into three groups, including low (≤ 3), moderate (4–6), and high-risk HEART/HEART2 scores (≥ 7). MACE occurrence of a patient with different risks of HEART and HEART2 scores and overall performance accuracy of HEART versus HEART2 score predicting MACE outcomes were compared.ResultsWe included a total of 9419 chest pain patients at ED, among which one out of five patients (1874/9419) had previous CIT performed. Fewer (38.2%) of such patients had low-risk HEART scores in comparison to 55.5% of low-risk HEART2 scores (p < 0.001). The MACE outcomes were similar in low-risk HEART patients compared with low-risk HEART2 patients (2.2% versus 3.1%, p = 0.3021). The overall performance accuracy of using the HEART2 score to stratify chest pain patients with previous CIT was better than using the HEART score’s (AUC 0.74 versus 0.71, p = 0.0082).ConclusionsUsing the HEART2 score might be suitable to stratify low-to-moderate risk chest pain patients at ED with a similar 30-days MACE occurrence compared to the HEART score. More importantly, with the use of similar low-risk criteria (HEART2 ≤ 3), over 45% more chest pain patients with previous CIT performed could be discharged directly from ED.

Performance of HEART and TIMI scores in predicting major adverse cardiovascular events (MACEs) of chest pain patients in the emergency department

The HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score is an easy-to-apply instrument to stratify patients with chest pain according to their short-term risk for major adverse cardiac events (MACEs), but its effect on daily practice is unknown. To measure the effect of use of the HEART score on patient outcomes and use of health care resources. Stepped-wedge, cluster randomized trial. (ClinicalTrials.gov: NCT01756846). Emergency departments in 9 Dutch hospitals. Unselected patients with chest pain presenting at emergency departments in 2013 and 2014. All hospitals started with usual care. Every 6 weeks, 1 hospital was randomly assigned to switch to "HEART care," during which physicians calculated the HEART score to guide patient management. For safety, a noninferiority margin of a 3.0% absolute increase in MACEs within 6 weeks was set. Other outcomes included use of health care resources, quality of life, and cost-effectiveness. A total of 3648 patients were included (1827 receiving usual care and 1821 receiving HEART care). Six-week incidence of MACEs during HEART care was 1.3% lower than during usual care (upper limit of the 1-sided 95% CI, 2.1% [within the noninferiority margin of 3.0%]). In low-risk patients, incidence of MACEs was 2.0% (95% CI, 1.2% to 3.3%). No statistically significant differences in early discharge, readmissions, recurrent emergency department visits, outpatient visits, or visits to general practitioners were observed. Physicians were hesitant to refrain from admission and diagnostic tests in patients classified as low risk by the HEART score. Using the HEART score during initial assessment of patients with chest pain is safe, but the effect on health care resources is limited, possibly due to nonadherence to management recommendations. Netherlands Organisation for Health Research and Development.

Background: Chest pain is a common emergency department (ED) presentation, and early risk stratification is essential to identify patients at risk of major adverse cardiac events (MACE).Objective: This study aimed to evaluate the diagnostic and prognostic utility of high-sensitivity troponin T (hs-TnT) and the HEART (history, ECG, age, risk factors, and troponin) score in predicting 30- and 45-day MACE among patients presenting with chest pain.Methodology: This descriptive observational study was conducted in two tertiary-care EDs in Pakistan (June 2021-May 2022). A total of 864 adult patients with non-traumatic chest pain were enrolled. Baseline demographics, clinical features, and risk factors were recorded. Initial hs-TnT levels were measured at presentation and serially at one and three hours. HEART scores were calculated at admission. MACE (myocardial infarction, revascularization, or cardiac death) within 30 and 45 days was defined according to standard criteria and adjudicated independently by blinded cardiologists. Associations between hs-TnT and outcomes were analyzed using chi-square tests for categorical variables and independent t-tests for continuous variables. Missing data were excluded from the analysis.Results: Among 864 patients (mean age 57.8 ± 13.1 years; 62% male), 144 (16.7%) developed 30-day MACE and 166 (19.2%) 45-day MACE. Patients with hs-TnT >52 ng/L had markedly higher MACE risk (30-day: 58.6%; 45-day: 63.8%) compared with those with hs-TnT <5 ng/L (30-day: 1.7%; 45-day: 1.9%, p<0.001). A HEART score ≥7 predicted 30-day MACE with 51.2% sensitivity, 87.3% specificity, a positive predictive value (PPV) of 28.2%, and a negative predictive value (NPV) of 94.6%. hs-TnT >52 ng/L alone showed 73.2% sensitivity, 79.4% specificity, PPV 35.7%, and NPV 95.9%. Combining hs-TnT >52 ng/L with HEART score ≥4 improved sensitivity to 84.2% and NPV to 97.2%. The area under the receiver operating characteristic (ROC) curve (AUC) for hs-TnT alone was 0.81 (95% CI: 0.77-0.85), for HEART score ≥7 was 0.76 (95% CI: 0.72-0.80), and for the combined model was 0.86 (95% CI: 0.83-0.89).Conclusion: Hs-TnT and the HEART score are effective, complementary tools for early identification of patients at risk of MACE. Serial hs-TnT measurement and combined use with HEART scoring significantly improve predictive accuracy, supporting their integration into ED risk stratification protocols.