HEART Score Research Articles

A double-blind, randomized, placebo-controlled, single-center clinical trial of jiaotaiwan for the treatment of insomnia symptoms caused by disharmony of the heart and kidney.

Background: Jiaotaiwan (JTW) is a classical tranquillizing prescription in traditional Chinese medicine (TCM) for the treatment of insomnia symptoms caused by disharmony of the heart and kidney (ISDHK). This study aimed to evaluate the effectiveness and safety of JTW for treating ISDHK in a double-blind, randomized, placebo-controlled trial. Methods: From September 2018 to February 2020, 128 participants with ISDHK were included in this single-center clinical trial. All participants were equally and randomly divided into either the JTW group (2-g JTW granules, b.i.d. for 7days) or placebo group (2-g placebo granules, b.i.d. for 7days). Pittsburgh Sleep Quality Index (PSQI) scores were set as the primary outcome, and polysomnography (PSG), 1H-magnetic resonance spectroscopy (1H-MRS), blood tests, and Disharmony of Heart and Kidney Scoring System (DHKSS) and clinical global impression (CGI) scores were used as secondary outcomes. Laboratory tests were used to evaluate the safety of JTW. All data were collected at baseline and posttreatment. Results: A total of 106 participants completed this clinical trial. Symptom relief was more apparent in the JTW group than the placebo group (PSQI total score: 9.34 ± 3.578 vs. 10.98 ± 3.073, respectively; p = 0.006). However, no PSG changes were observed between the two groups (p > 0.05). Higher CGI and lower DHKSS scores were observed after JTW treatment. Serum melatonin was increased in patients with ISDHK after JTW treatment (JTW, 339.09 ± 256.894 vs. placebo, 219.59 ± 169.045; p = 0.004). There were significant posttreatment differences in metabolites in the left cerebellum between the two groups (myoinositol: JTW, 13.47 ± 2.094 vs. placebo, 12.48 ± 2.449; p = 0.021; choline: JTW, 3.96 ± 0.657 vs. placebo, 3.65 ± 0.562; p = 0.008). In terms of safety, JTW had no noticeable adverse effects relative to placebo. Conclusion: JTW was effective and well tolerated for the treatment of ISDHK. The development of large-scale trials with longer follow-up durations is recommended to provide further evidence. Clinical Trial Registration: clinicaltrials.gov, identifier ChiCTR1800019239.

Investigation of the association between serum uric acid levels and HEART risk score in patients with acute coronary syndrome.

The association between uric acid (UA) and cardio-metabolic conditions has been recognized for a long time. However, recently, a body of evidence has highlighted the independent role of UA in a series of conditions, including renal and cardiovascular diseases. In this light, data regarding the prognostic role of UA in acute coronary syndrome (ACS) is scarce. A total number of 100 patients, 59 males and 41 females, diagnosed with ACS were recruited in this study. At the time of admission to the hospital, the serum level of UA was measured. In addition, the HEART score was calculated based on each patients' profile. Participants were on average 61.37 ± 12.08 years old. The most prevalent risk factors were hypertension (48%), a history of coronary artery disease (40%), and diabetes mellitus (33%). The average serum level of UA was 5.81 ± 1.81 mg/dl, and the calculated HEART score had a median of six (minimum of two and maximum of ten). A positive yet statistically insignificant correlation was found between the measured UA level and the calculated HEART score (R= 0.375, p= 0.090). However, further studies with larger sample size are required to assess the direct association of UA level with major adverse cardiac events in patients with cardiovascular disease.

A Prospective Validation Of The Heart Score For Chest Pain Of South Indian Patients At The Emergency Department

A Prospective Validation Of The Heart Score For Chest Pain Of South Indian Patients At The Emergency Department

17 Heritability Estimate of Heart Score

Abstract Feedlot heart disease (FHD), also known as bovine congestive heart failure, affects feedlot cattle at low to moderate elevations. This disease can cause feedlot death and preliminary research suggests unfavorable influences on performance and carcass quality in those individuals reaching their harvest endpoint. The severity of FHD for an individual animal at harvest can be determined by a heart scoring system that ranges from 1 to 5 corresponding to the increasing degree of heart failure with a score of 1 a normal heart and larger scores indicative of increased malformations. Heart scores (HS) are collected on individual animals at harvest. Previous research indicated that differences exist between sires as to their progeny’s propensity for developing FHD as indicated by HS of 3, 4 and 5. As a result of these sire differences, the objective of this study was to estimate heritability of HS obtained from a group of fattened feedlot cattle. Heart scores, numbers of cattle (Grade 1: 290 ; Grade 2: 728; Grade 3: 340; Grade 4: 64; Grade 5: 0) pedigree, and feedlot pen information were collected from 1,422 individual animals. The pedigree used in the evaluation consisted of the 1,422 individuals and 89 unique sires. No dam information was available on the scored animals. Heritability was estimated using a mixed effect animal model and the statistical software package ASReml 3.0. Fixed effects included scorer, sex, and kill age. Sex was not found to be significant in the model. Individual animal was included as the sole random effect. Scorer (P < 0.05) and kill age (P < 0.1) were found to influence variability in heart score, although kill age was detected as a tendency (P = 0.07). The heritability of HS was estimated to be 0.27 ± 0.10. The genetic variation was 0.15 and the phenotypic variation in the model was 0.40. These results suggest, HS is moderately heritable and has the potential to respond to genetic selection.

Evaluation of the Practice Guideline Used for Rule-Out of Myocardial Infarction at a Tertiary Cardiology Center.

With the current high burden on the healthcare system and limited resources, the efficient utilization of facilities is of utmost importance. We sought to present the practice guideline used at a high prevalence tertiary cardiology center and compare its safety and efficacy performance with the single high-sensitivity cardiac troponin T strategy, conventional and modified HEART score. In this prospective cohort study, consecutive patients presenting to the emergency department with chest pain or an angina equivalent were recruited. The primary endpoints consisted of major adverse cardiac events at index visits and 30-day follow-up. Patients were managed according to the practice guideline, and sensitivity and negative predictive values were compared. Of the total 1548 patients, the mean age was 50.4 ± 15.7 years. Ninety-nine (10.9%) patients were admitted at the index visit, and 89 patients were consequently diagnosed with acute coronary symptoms. Six (0.007%) patients experienced major adverse cardiac events within the 30-day follow-up among discharged patients. Among 911 patients with at least 1 troponin, using single high-sensitivity cardiac troponin T, HEART score, and modified HEART score would have further admitted 805, 450, and 609 patients, respectively. The negative predictive value for all 4 algorithms did not significantly differ (99.2% vs. 100% vs. 99.3% vs. 99.6%, respectively). The Tehran Herat Center protocol was a relatively safe protocol with high efficacy. Despite the high safety of the other diagnostic pathways, the high volume of patients needing additional evaluation could impose a high burden on the health care system.

Correlation between NSTE-ACS risk scores with Syntax: can we predict coronary lesion complexity before angiography?

Abstract Background and aim Standard single antiplatelet regimen (SAPT) is currently recommended before invasive risk stratification in non-ST elevation acute coronary syndromes (NSTE-ACS). However, there are subsets in whom dual antiplatelet therapy (DAPT) may be more protective according to the coronary anatomy and revascularization strategy. We aimed to identify pre-procedural predictors of coronary artery complexity that may be helpful in selecting an individualized antiplatelet regimen. Methodology Retrospective single-center study including patients with NSTE-ACS performing coronary angiography between January 2020 and July 2021. Clinical variables and classical NSTE-ACS risk scores (TIMI, GRACE and HEART) were captured and SYNTAX 1 score was calculated. Patients were divided into low (0–22), moderate (23–32) and high (≥33) SYNTAX score. Multivariate logistic regression analysis was performed to determine predictors of anatomical complexity (defined as significant left main disease [stenosis ≥50%] or SYNTAX ≥33). Results A total of 448 patients were included (mean age 67±13 years; 74% males; 85% with NSTE-myocardial infarction). Overall, 350 (78%), 63 (14%) and 35 (8%) patients had a low, moderate or high-SYNTAX score, respectively. Thirty-one (7%) patients had significant left main disease. At multivariate analysis (adjusted for age, diabetes, renal function, GRACE and TIMI scores), the HEART score (hazard ratio 2.3, 95% confidence interval 1.5–3.3, p<0.001) predicted a high anatomical complexity. When performing ROC curve analysis, the HEART score had a high discriminative ability in identifying those with complex coronary anatomy (area under the curve 0.79, 95% CI 0.72–0.86, p<0.001) (Figure 1) – a score >7 showed a sensitivity of 76% and specificity of 75% in identifying such patients. Conclusion In this cohort of NSTE-ACS patients, the HEART score was an independent predictors of complex coronary anatomies. These results suggest that those with high (>7) HEART score may merit from SAPT as opposed to DAPT, given the high probability of complex lesions amenable to CABG. Funding Acknowledgement Type of funding sources: None.

Coronary artery calcium score in people living with HIV. Results from the French CAC study

Abstract Background People living with HIV (PLWH) have a higher risk of CAD. Whether coronary artery calcification (CAC) score could better stratify the CV risk remains debated in this middle age population. Purpose We conducted the French CAC score study to compare the CAC score between PLHIV and HIV− subjects at intermediate risk. Methods 689 subjects (257 PLHIV and 432 HIV−) were consecutively addressed for CV risk evaluation including CAC score assessment in 2 centers between 2013 and 2019. Subjects were included if they were 18 years'old or older, had no known cardiovascular disease and had a CAC score along with cardiometabolic assessment. Results The mean age of the cohort was 59.3 years ± 10.7 and predominantly male (54%). PLHIV were younger (55.8 years ± 9.1 vs 61.3±11.3, p<0.004), with a lower rate of diabetics (18% vs 26%, p=0.009) and lower levels of total cholesterol, LDLc, and HDLc (2.0 mmol/l vs, 2.2 mmol/l; 1.2 mmol/L vs 1.3 mmol/L; and 1.2 mmol/L vs 1.4 mol/L respectively, all p<0.001). The prevalence of hypertension, dyslipidemia and obesity was similar between PLHIV and the HIV− group (40%, 43% and 21%, respectively). No differences were observed in CV therapies prescribed including antihypertensive drugs and statins between PLHIV and the HIV− group (39% vs 37%, p=0.54 and 46% vs 39%, p=0.065). In contrast, PLHIV had higher rate of triglycerides (1.4 mmol/L vs 1.2 mmol/L, p=0.01), higher rate of active smoking (28% vs 14%, p<0.001), CRP level (4.0 mg/L vs 2.9 mg/L, p<0.001) along with higher black ethnicity representation (17% vs 5%;, p<0.001). 96% of PLHIV were under antiretroviral therapy at the time of enrollment with 88% who had been exposed to protease inhibitors. In subjects who had carotid and/or limb ultrasound evaluation (67% and 45% respectively in PLHIV and HIV), no increased rate of arterial stenosis >50% was found (13% vs 8%, p=0.16). Concerning, CV risk estimation using 10-year ASCVD and HEART scores, we observed that the median ASCVD score was similar between PLHIV and HIV− group (10.7% vs 9.8, p=0.15) but that PLHIV had a higher HEART score (3.0% vs 2.0%, p<0.001). The repartition between the ASCVD or HEART scores classes between the 2 groups was similar with 80% of the cohort classified as low or intermediate CV risk with the ASCVD score and 88% at intermediate or borderline CV risk with the HEART score. However, no statistically significant differences was found between the 2 groups regarding the prevalence of CAC = 0 (41% vs 44%, p=0.52) and the median CAC score (7.7 vs 8.2, p=0.81). Conclusion In this cohort of subjects at intermediate CV risk according to CV risk scores estimation (ASCVD or HEART scores), PLHIV had a similar prevalence of CAC = 0 and median CAC scores as compared to HIV− subjects despite a younger age (6 years). Longitudinal follow up will explore whether this similar CAC score evaluation will be translated into higher CV events. Funding Acknowledgement Type of funding sources: None.

Direct comparison of very early AMI rule-out algorithms

Abstract Introduction Early rule-out of AMI may have a considerable impact on healthcare spending. Numerous algorithms for early rule-out of AMI has been suggested within the last year. However, most algorithms are limited by the need for consecutive, timely separated in-hospital blood samples, prolonging length of hospital stay. Very early rule-out algorithms, providing necessary biomarker results shortly after arrival to hospital or even before, could reduce the burden on EDs and cardiology departments. Many algorithms have been evaluated, validated and compared in several studies; however, often in different subpopulations of larger studies. Reported differences in diagnostic performance of these algorithms may very likely have been caused by differences between the tested patient subgroups. Therefore, a direct comparison of very early rule-out algorithms in a single cohort with all necessary information available for all algorithms is needed. Purpose In this study we aimed to compare the ESC 0h/1h algorithm with ten rule-out algorithms, including the ESC 0h/3h algorithm, an in-hospital Dual-Marker strategy (DMS) (combining hs-cTnT with copeptin), and seven very early algorithms (potential rule-out at admission) for rule-out of AMI. Four algorithms are strictly prehospital and three combines prehospital and in-hospital blood samples, see table 1 for description of evaluated algorithms. Methods The diagnostic performance of the rule-out algorithms was compared in patients with suspected AMI from a randomized, controlled, multicenter trial. We only included patients who had all required information for each diagnostic algorithm available. AMI was adjudicated by at least two cardiologists. Results We included 1.601 patients, see table 2. Of these 136 (8.5%) had type 1 AMI. We found that 7 of 11 algorithms, including the present ECS-recommended 0h/1h algorithm, performed with acceptable sensitivities above 98% and specificities between 13.5 and 52.0%. The ESC 0h/3h algorithm had a unacceptably low sensitivity of 87.5%. Four of the very early rule-out algorithms (the HEART score, the Modified prehospital HEART score, the Modified prehospital DMS, and the Modified prehospital/in-hospital DMS) all performed with excellent sensitivity of 100% and thereby missing no AMIs. Of these, the HEART score derivates ruled out 13.5–16.2% of pts. without AMI, while the two DMS derivates ruled out 14.3–27.4% of pts without AMI. Compared with the ESC 0h/1h algorithm the very early rule out algorithms provide the necessary biomarker results at least 1 hour earlier, and when well-performing POCT analyses becomes available for copeptin and troponin analysis, even before arrival to hospital. Conclusions Four very early rule out algorithms performed excellent in the rule out of AMI, with 100% sensitivities and specificities of up to 27.4%. This enables safe rule out of AMI shortly after arrival to hospital, and in future, potentially already in the ambulance. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National budget only - Danish Heart Foundation and Independent Research Fund Denmark

Evaluation of acute chest pain – is it possible to associate cardiovascular risk scores (TIMI, HEART, GRACE) and the presence of obstructive plaque on coronary computed tomography angiography?

Abstract Introduction Coronary artery disease (CAD) answers for almost 43.2% of cardiovascular deaths worldwide. In the United States, more than 8 million patients present to the emergency department each year with acute chest pain. Although, as few as 10% will be diagnosed with acute coronary syndrome. Cardiovascular risk scores are frequently used as tools to evaluate the chance of coronary disease, despite the fact that they were initially validated as prognostic schemes to categorize a patient's risk of death and ischemic events. The association of these scores and the presence of obstructive atherosclerotic plaques is scarce. Purpose To associate the presence of obstructive atherosclerotic plaque on coronary computed tomography angiography (CCTA) and cardiovascular risk scores, in the evaluation of patients who present with acute chest pain to the emergency department in a tertiary referral center in cardiovascular disease. Methods This is an observational and retrospective study that evaluated patients presenting to the emergency department with acute chest pain and were referred to CCTA. Exclusion criteria were ischemic EKG signs, positive troponin or history of coronary revascularization. CCTA images were reviewed by trained observers who performed a per-segment analysis to assess coronary artery stenosis, with complex cases classified by consensus. Atherosclerotic plaque was categorized as obstructive if luminal cross-sectional area stenosis was >50% in ≥1 major epicardial artery. Results Overall, 350 patients were recruited (52.6±11.9 years, 50% women) in whom 20.6% (72 patients) had significant atherosclerotic plaque. Male gender (OR: 1.87; 95% CI: 1.08–3.26), age >52 years (OR: 2.85; 95% CI: 1.6–5.07), diabetes (OR: 2.17; 95% CI: 1.12–4.2) and typical angina (OR: 2.17; 95% CI: 1.12–4.2) were the only clinical characteristics independently associated with the presence of obstructive plaque. More then 90% of patients with significant coronary stenosis were classified as low risk by GRACE and TIMI scores. HEART score was <4 in 23.6% of patients with obstructive plaque. Conclusion In patients who present to the emergency department in a tertiary referral hospital with acute chest pain, the initial evaluation based on clinical characteristics and cardiovascular risk scores was not sufficient to exclude safely the presence of coronary artery disease. Therefore, in such patients, CCTA could help to identify those with occult CAD and to target preventative treatments, thereby improving clinical outcomes. Funding Acknowledgement Type of funding sources: None.

Evaluation of the Marburg Heart Score and INTERCHEST score compared to current telephone triage for chest pain in out-of-hours primary care

Abstract Background/Introduction Chest pain is a common and challenging symptom for telephone triage in urgent primary care. Existing chest pain-specific risk scores originally developed for diagnostic purposes may perhaps outperform current, expert-based and unvalidated telephone triage protocols. Purpose To evaluate the performance of the Marburg Heart Score (MHS) and INTERCHEST as stand-alone triage tools, and to compare their performance with the current “Netherlands Triage Standard (NTS) protocol on differentiating major events”. Methods This study involved a retrospective, observational cohort of consecutive patients evaluated for chest pain at a large-scale out-of-hours primary care facility in the Netherlands. We evaluated the performance of the MHS and INTERCHEST score as stand-alone triage tools and compared them with the current decision support tool (NTS). The outcomes of interest were; C-statistics, calibration and diagnostic accuracy for optimized thresholds with major events as reference standard. Major events are a composite of all-cause mortality and both cardiovascular and non-cardiovascular urgent conditions requiring in-hospital treatment, occurring within 6 weeks of initial contact. Results We included 1,433 patients, 57.6% women, with a median age of 55.0 years. Major events occurred in 16.4% (n=235), of which acute coronary syndrome (ACS) accounted for 6.8% (n=98). For predicting major events, C-statistics for MHS and INTERCHEST were 0.74 [95%-CI: 0.70–0.77] and 0.76 [0.73–0.80], respectively. In comparison, NTS had a C-statistic of 0.66 [0.62–0.69]. All had appropriate calibration. Both scores (at threshold ≥2) reduced the number of referrals (with lower false positive rates) and maintained equal safety compared with NTS. Conclusion Diagnostic risk stratification scores for chest pain may also improve telephone triage for major events in out-of-hours primary care, by reducing the number of unnecessary referrals without compromising on triage safety. Further validation is warranted. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Amsterdam Cardiovascular Research InstituteZonMw-HGOG

A Closer Look at the HEART Score.

The history, electrocardiogram, age, risk factors, and troponin (HEART) score is currently a widely used tool for acute chest pain risk stratification. Relatively soon after its inception in 2008, a number of validation studies on the HEART score showed it to be superior to Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) scores and at least as accurate to other existing scores for predicting short-term major adverse cardiovascular events (MACEs). However, partly due to its focus on simplicity, the HEART score has some limitations. In this article we review how the HEART score has evolved and taken on various modifications to circumvent some of its limitations. We also highlight the strength of the HEART score in comparison with other risk stratification tools and the current guidelines.

289 Impact of an Emergency Department Quality Improvement Initiative to Promote Safe Discharge of Low-Risk Chest Pain Patients

Through participation in the Michigan Emergency Department Improvement Collaborative (MEDIC), an interdisciplinary team of physicians, advanced practice professionals, and nurses aimed to increase the safe discharge rate of adult low-risk chest pain patients. The purpose of this quality improvement project was to implement a standardized clinical pathway, including the use of the HEART score to promote the safe discharge of low-risk emergency department (ED) patients with chest pain.

IMPROVEMENT OF INCEPTIONV3 MODEL CLASSIFICATION PERFORMANCE USING CHEST X-RAY IMAGES

In this study, we attempted to confirm whether the InceptionV3 model, which shows excellent performance in lung disease classification using chest X-ray images, is suitable for cardiac disease classification. In addition, we proposed a method for improving classification accuracy by improving the structure of the existing InceptionV3 model. The deep learning model used in this study was a modified version of the fully-connected hierarchical structure of InceptionV3. The proposed InceptionV3 model structure was constructed to differentiate between a normal heart and hypertrophic heart. The data used for model training were trained after data augmentation on 1026 chest X-ray images of patients diagnosed with normal heart and cardiac hypertrophy at Kyungpook National University Hospital. The experiment showed a learning classification accuracy of 99.57% and loss of 1.42% for the original InceptionV3 model. The accuracy and loss of the modified InceptionV3 model were 99.81% and 0.92%, respectively. Its classification performance was evaluated based on precision, recall, and F1 score. For a normal heart, precision, recall and F1 score were 78%, 100% and 88%, respectively. For cardiomegaly, classification accuracy, recall and F1 score were 78%, 100% and 88%, respectively. Conversely, the modified model showed 100% precision, 92% recall and 96% F1 score. For cardiomegaly, classification accuracy, recall rate and F1 score were 95, 100 and 97%, respectively. In conclusion, better classification can be achieved if the chest X-ray images for a normal heart and cardiomegaly are classified using the proposed model. Hence, the reliability of the classification performance gradually increases.

PSV-A-11 The Effect of Days on Feed for Feedyard Performance, Health, Carcass, and Organ Characteristics of Angus X Holstein Heifers

Abstract The objective of this study was to evaluate the effect of days on feed (DOF) on performance, health, carcass, and organ characteristics of composite Angus x Holstein heifers (n = 3,676). At time of arrival (d 0), heifers from a single source were placed into large (~300 animal) pens at two commercial feedlot locations in the Texas Panhandle. At administration of final implant (Revalor® 200; d 240), heifers, within lot, were randomly assigned to one of four smaller pens, creating a block (location A block n = 6, location B block n = 7). Pens within blocks were randomly assigned to treatment (323, 344, 365, or 386 DOF). Data were analyzed using DOF as the fixed effect; block was nested within location as a random effect. Linear and quadratic effects were also tested; pen was experimental unit (n = 52). Heifer DMI did not differ across DOF (P = 0.72). Heifer ADG decreased linearly (1.52, 1.37, 1.31, and 1.27 kg/d; P ≤ 0.01). Heifer HCW (372, 387, 401, and 414 kg), longissimus dorsi muscle area (88.63, 89.55, 90.80, and 91.95 cm2), marbling score (535, 553, 563, and 594) and percentage of Prime QG (6.6, 11.2, 12.8, and 19.0 %) linearly increased (P ≤ 0.01) as DOF increased. Frequency of liver scores (edible, minor, or major abscess) did not change over DOF (P ≥ 0.82). Frequency of ideal heart score linearly decreased with DOF (53.0, 44.3, 25.7, and 15.0 %; P ≤ 0.01). Frequency of YG 3 did not change (P = 0.68), however YG 4 linearly increased with DOF (6.2, 12.0, 14.0, and 22.5 %; DOF P ≤ 0.01). Data collected in this trial indicate that DOF led to increased HCW, LM area, marbling, YG, and QG with minimal changes to DMI or liver scores for Angus x Holstein heifers.

The Correlation between Clinical Risk Score (Heart, Grace and TIMI) and Angiographic Coronary Artery Complexity in NSTEMI

The GRACE, HEART and TIMI scores have been well validated for assessment of prognosis in non-ST- elevation acute coronary syndrome (NSTE-ACS). However, their value in predicting coronary artery disease (CAD) has been little studied. In this paper, we aimed to assess the relationship between these scores and the extent of coronary disease, by studying 183 cases with NSTEMI, from cardiology department in Mohamed VI university hospital center in Marrakesh. Results showed a positive correlation between the SYNTAX and the HEART and GRACE scores, but the correlation with TIMI reached no statistical significance.

Breed-specific values for vertebral heart score (VHS), vertebral left atrial size (VLAS), and radiographic left atrial dimension (RLAD) in pugs without cardiac disease, and their relationship to Brachycephalic Obstructive Airway Syndrome (BOAS).

This prospective study aims to establish reference ranges for vertebral heart score (VHS), vertebral left atrial size (VLAS), and radiographic left atrial dimension (RLAD) in pugs. The impact of clinical severity of Brachycephalic Obstructive Airway Syndrome (BOAS), gender, body condition score, and body weight on VHS, VLAS, and RLAD were investigated. Intra- and interobserver correlation was determined. Correlation of radiographic scores to echocardiographic left atrial dimension was inspected. Additionally, for VLAS and RLAD, correlation to VHS was examined. Additionally, an assessment of thoracic and vertebral malformations was performed. Forty-seven privately owned pugs underwent physical examination, echocardiography, and thoracic radiography to determine cardiac health. Thirty-two pugs were eligible for establishing reference ranges for VHS in right lateral radiographs, which was 11.25 ± 0.62 (95% range, 10.1–12.8). Reference ranges for VHS in left lateral, and for VLAS and RLAD in right lateral radiograph were determined in 30 pugs. The VHS in left lateral radiograph was 11.01 ± 0.70 (95% range, 9.4–12.6), VLAS was 1.96 ± 0.38 (95% range, 1.1–2.8), and RLAD was 1.59 ± 0.34 (95% range, 0.7–2.4). Clinical severity of BOAS did not show any impact on radiographic measurements. For VLAS, a significant correlation to VHS was detected by all observers. No other variables had a consistent influence on the radiographic scores given by all observers. Interobserver agreement was almost perfect for VHS (0.89 on right lateral and 0.91 on left lateral image), moderate for VLAS (0.49), and fair for RLAD (0.22). More than one third of the entire study population (18 of 47 pugs) showed at least one thoracic cavity or spine abnormality, often leading to considerable changes in vertebral body shape and size.

Association between feline hyperthyroidism and thoracic radiographic evaluation of cardiomegaly and pulmonary hyperinflation.

Hyperthyroidism frequently affects middle-to-older-aged cats that can present with cardiorespiratory signs. The effects of hyperthyroidism on cardiac size and function have been previously documented. Anecdotally, pulmonary hyperinflation identified on thoracic radiographs may also be associated with hyperthyroidism; however, there is no literature to support this claim. The goal of this study was to determine any association between hyperthyroidism, pulmonary hyperinflation and cardiomegaly with the following hypotheses: (1) hyperthyroid cats would not have evidence of radiographic pulmonary hyperinflation compared with control cats; and (2) hyperthyroid cats were more likely to have evidence of radiographic cardiomegaly than control cats. In this retrospective case-control study, the thoracic radiographs of 52 hyperthyroid cats and 46 non-hyperthyroid cats were evaluated for subjective and objective measurements of pulmonary hyperinflation and cardiomegaly. There were no statistically significant differences between hyperthyroid and non-hyperthyroid cats for any variable indicative of pulmonary hyperinflation. The mean ± SD vertebral heart score on lateral views for hyperthyroid cats was 7.75 ± 0.53 and for control cats was 7.55 ± 0.54, which was significantly different (P = 0.05). Among all cats, a more severe total elevation in thyroxine (T4) was correlated with a larger vertebral heart score on lateral views (Spearman's correlation coefficient = 0.23, P = 0.02). While the results of this study suggest that hyperthyroid cats are more likely to have a larger vertebral heart score on lateral views than control cats, the clinical relevance of this finding is unclear given the large degree of overlap between hyperthyroid and non-hyperthyroid cats. In addition, among all cats, a greater total T4 elevation was weakly correlated with a larger vertebral heart score. Hyperthyroidism is not associated with radiographic pulmonary hyperinflation and is an unlikely differential for this radiographic finding.

Performance of CARE rule in ruling out acute coronary syndrome in non-traumatic chest pain: an external validation study

Objective: About one out of every 10 patients with chest pain in the emergency department (ED) are finally diagnosed with acute coronary syndrome (ACS). A HEART score of ≤ 3 has been shown to rule out ACS with a low risk of major adverse cardiac events (MACE) occurrence. It has been proposed that a negative CARE rule (≤1), which stands for the first four elements of the HEART score and excludes the troponin assay requirement, may have similar rule-out reliability. This study aimed to externally validate the CARE rule.
 Methods: In this multicenter, observational study a convenience sample consisting of patients over the age of 15 who had at least one troponin study were included. The performance of the CARE rule at the cut-off ≤1 for MACE prediction was assessed and compared to a HEART score of ≤3 and physicians’ gestalt. MACE was defined as myocardial infarction, coronary angioplasty, coronary artery bypass graft, and all-cause mortality in 6 weeks.
 Results: The data of 154 patients was analyzed. Of these, 121 patients had a negative CARE score of ≤1 and 33 individuals had a positive CARE score. Of those with a negative CARE score, only 1 (3%) experienced an adverse cardiac event while in those with a positive CARE score, 26 individuals (16.88 %) experienced MACE. The sensitivity of the CARE rule was 96.15% and the specificity was 25% with a negative likelihood ratio (LR-) of 0.15. The indices for HEART score were 88%, 59.69%, and 0.2, respectively. In comparison, physicians' gestalt had a sensitivity of 96%, specificity of 49.22%, and a LR- of 0.08. Of note, utilizing the CARE rule with a cut-off of <3 showed sensitivity of 96%, specificity of 41.86%, and a LR- of 0.1.
 Conclusion: The CARE rule miss rate in MACE was more than 2% and while its performance was better than the HEART score, physicians’ gestalt outperformed both rules for ruling out MACE.

The Value of Different Short-Term Risk Scoring Models in Predicting Long-Term Death of Acute Myocardial Infarction.

Background and aims: To compare the value of three commonly used cardiovascular short-term risk scoring models, the GRACE score, TIMI score, and HEART score, in predicting the long-term prognosis of patients with acute myocardial infarction. Methods: The hospitalization data of patients who were hospitalized in West China Hospital of Sichuan University from 2011 to 2013 and diagnosed with acute myocardial infarction (AMI) were collected. The patients were scored by GRACE score, TIMI score, and HEART score. The long-term follow-up of patients was conducted until the end of January 2021. All-cause death and time of death of patients were confirmed by telephone follow-up, electronic medical record query, and household registration information. The predictive ability of different risk scores for long-term prognosis was compared according to the receiver operating characteristic (ROC) area under the curve (AUC), and the ability to distinguish patients with different risk levels was compared according to Kaplan–Meier survival curves. Results: The study ultimately included 2220 patients, with a median follow-up of 8 years and 454 (20.5%) deaths until the end of follow-up. Whether in ST-segment elevation myocardial infarction (STEMI) patients or non-ST-segment elevation myocardial infarction (NSTEMI) patients, the AUC value of the GRACE score (both AUC = 0.734) was significantly higher than the TIMI score (AUC = 0.675, p < 0.01; AUC = 0.665, p < 0.01) and HEART score (AUC = 0.632, p < 0.01; AUC = 0.611, p < 0.01) until the end of follow-up. In terms of risk stratification, the Kaplan–Meier survival curve shows that both THE GRACE score and TIMI score can distinguish AMI patients with different risk levels (p < 0.01), but the risk stratification ability of the HEART score in AMI patients was poor (p > 0.05). Conclusion: The GRACE risk score could represent a more accurate model to assess long-term death of acute myocardial infarction, but further studies are required.

Hot off the press: SGEM#370: Listen to your HEART (score) … MACE incidence in non-low-risk patients with known coronary artery disease.

The HEART Score and Pathway risk stratify patients with chest pain into low, moderate, and high risk for major adverse cardiac events (MACE). The moderate risk group can be further divided into patients with and without known prior coronary artery disease (CAD). This article summarizes the podcast and blog post discussing the study by Henderson et al which attempts to risk stratify this group by presence of known CAD.