Skip to main content
SpringerLink
Log in

The Role of Using HEART Score to Risk Stratify Chest Pain Among Emergency Department High Utilizers

  • Original article
  • Published:
High Blood Pressure & Cardiovascular Prevention Aims and scope Submit manuscript

Abstract

The HEART score is used to effectively risk stratify undifferentiated chest pain patients in the Emergency Department (ED). It is unclear whether such risk stratification can be applied among ED high utilizers. We aim to determine the efficacy and safety of using the HEART score to predict 30-day short-term major adverse cardiac events (MACE) in ED high utilizers. We conducted a retrospective, observational study in which ED high utilizers were defined as patients who had four or more ED visits within the past 12 months. ED high utilizers presenting at the study ED with chest pain were enrolled. Patients in which the HEART score was utilized were placed in the HEART group and patients with no HEART scores documented were placed to the usual care group. Hospital admissions and cardiac stress tests performed during the index hospitalizations, and 30-day MACE rates were analyzed and compared between the HEART and usual care groups. From January 1, 2017 to December 31, 2019, a total of 8,315 patient visits from ED high utilizers were enrolled. In the HEART group, 49% of ED visits were admitted with 20% receiving stress tests. A 30-day MACE outcome occurred among 1.4% of visits. In the usual care group, 44% of ED visits were admitted, with only 9% receiving index stress tests and a 1.5% of 30-day MACE occurrence (p=0.727). The study showed that similar short-term MACE outcomes occurred between patients using HEART scores and usual care to risk stratify chest pain among ED high utilizers.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Nawar EW, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary. Adv Data. 2007;2007:1–32.

    Google Scholar 

  2. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Natl Health Stat Report. 2007;2010:1–31.

    Google Scholar 

  3. Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008;16:191–6.

    Article  CAS  Google Scholar 

  4. Wang H, Watson K, Robinson RD, Domanski KH, Umejiego J, Hamblin L, Overstreet SE, Akin AM, Hoang S, Shrivastav M, Collyer M, Krech RN, Schrader CD, Zenarosa NR. Chest pain risk scores can reduce emergent cardiac imaging test needs with low major adverse cardiac events occurrence in an emergency department observation unit. Crit Pathw Cardiol. 2016;15:145–51.

    Article  Google Scholar 

  5. Poldervaart JM, Langedijk M, Backus BE, Dekker IMC, Six AJ, Doevendans PA, Hoes AW, Reitsma JB. Comparison of the GRACE, HEART and TIMI score to predict major adverse cardiac events in chest pain patients at the emergency department. Int J Cardiol. 2017;227:656–61.

    Article  CAS  Google Scholar 

  6. Backus BE, Six AJ, Kelder JC, Bosschaert MA, Mast EG, Mosterd A, Veldkamp RF, Wardeh AJ, Tio R, Braam R, Monnink SH, van Train R, Mast TP, van den Akker F, Cramer MJ, Poldervaart JM, Hoes AW, Doevendans PA. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013;168:2153–8.

    Article  CAS  Google Scholar 

  7. Laureano-Phillips J, Robinson RD, Aryal S, Blair S, Wilson D, Boyd K, Schrader CD, Zenarosa NR, Wang H. HEART score risk stratification of low-risk chest pain patients in the emergency department: a systematic review and meta-analysis. Ann Emerg Med. 2019;74:187–203.

    Article  Google Scholar 

  8. Mahler SA, Hiestand BC, Goff DC Jr, Hoekstra JW, Miller CD. Can the HEART score safely reduce stress testing and cardiac imaging in patients at low risk for major adverse cardiac events? Crit Pathw Cardiol. 2011;10:128–33.

    Article  Google Scholar 

  9. Hyams JM, Streitz MJ, Oliver JJ, Wood RM, Maksimenko YM, Long B, Barnwell RM, April MD. Impact of the HEART pathway on admission rates for emergency department patients with chest pain: an external clinical validation study. J Emerg Med. 2018;54:549–57.

    Article  Google Scholar 

  10. Gafni-Pappas G, DeMeester SD, Boyd MA, Ganti A, Nicholson AM, Albright J, Wu J. The HAS-Choice study: Utilizing the HEART score, an ADP, and shared decision-making to decrease admissions in chest pain patients. Am J Emerg Med. 2018;36:1825–31.

    Article  Google Scholar 

  11. Van Den Berg P, Body R. The HEART score for early rule out of acute coronary syndromes in the emergency department: a systematic review and meta-analysis. Eur Heart J Acute Cardiovasc Care. 2018;7:111–9.

    Article  Google Scholar 

  12. Hardy M, Cho A, Stavig A, Bratcher M, Dillard J, Greenblatt L, Schulman K. Understanding frequent emergency department use among primary care patients. Popul Health Manag. 2018;21:24–31.

    Article  Google Scholar 

  13. Moulin A, Evans EJ, Xing G, Melnikow J. Substance use, homelessness, mental illness and medicaid coverage: a set-up for high emergency department utilization. West J Emerg Med. 2018;19:902–6.

    Article  Google Scholar 

  14. Kirkpatrick S, Agana DFG, Lynch K, Carek PJ. Emergency department high utilizers among family medicine patients. J Am Board Fam Med. 2019;32:264–8.

    Article  Google Scholar 

  15. Du J, Zhang D, Yin Y, Zhang X, Li J, Liu D, Pan F, Chen W. The personality and psychological stress predict major adverse cardiovascular events in patients with coronary heart disease after percutaneous coronary intervention for five years. Med (Baltim). 2016;95:e3364.

    Article  Google Scholar 

  16. Habra ME, Linden W, Anderson JC, Weinberg J. Type D personality is related to cardiovascular and neuroendocrine reactivity to acute stress. J Psychosom Res. 2003;55:235–45.

    Article  Google Scholar 

  17. Cline DM, Silva S, Freiermuth CE, Thornton V, Tanabe P. Emergency Department (ED), ED observation, day hospital, and hospital admissions for adults with sickle cell disease. West J Emerg Med. 2018;19:311–8.

    Article  Google Scholar 

  18. LaCalle E, Rabin E. Frequent users of emergency departments: the myths, the data, and the policy implications. Ann Emerg Med. 2010;56:42–8.

    Article  Google Scholar 

  19. Fernando SM, Tran A, Cheng W, Rochwerg B, Taljaard M, Thiruganasambandamoorthy V, Kyeremanteng K, Perry JJ. Prognostic Accuracy of the HEART score for prediction of major adverse cardiac events in patients presenting with chest pain: a systematic review and meta-analysis. Acad Emerg Med. 2019;26:140–51.

    Article  Google Scholar 

  20. Hunt KA, Weber EJ, Showstack JA, Colby DC, Callaham ML. Characteristics of frequent users of emergency departments. Ann Emerg Med. 2006;48:1–8.

    Article  Google Scholar 

  21. Chambers C, Chiu S, Katic M, Kiss A, Redelmeier DA, Levinson W, Hwang SW. High utilizers of emergency health services in a population-based cohort of homeless adults. Am J Public Health. 2013;103(Suppl 2):S302–10.

    Article  Google Scholar 

  22. Hollander JE, Than M, Mueller C. State-of-the-art evaluation of emergency department patients presenting with potential acute coronary syndromes. Circulation. 2016;134:547–64.

    Article  Google Scholar 

  23. Kolff AQ, Bom MJ, Knol RJ, van de Zant FM, van der Zee PM, Cornel JH. Discriminative power of the HEART score for obstructive coronary artery disease in acute chest pain patients referred for CCTA. Crit Pathw Cardiol. 2016;15:6–10.

    Article  Google Scholar 

  24. Roongsritong C, Taha ME, Pisipati S, Aung S, Latt H, Thomas J, Namballa L, Al-Hasnawi HJ, Taylor MK, Gullapalli N. SVEAT Score, a potential new and improved tool for acute chest pain risk stratification. Am J Cardiol. 2020;127:36–40.

    Article  Google Scholar 

  25. Poldervaart JM, Reitsma JB, Backus BE, Koffijberg H, Veldkamp RF, Ten Haaf ME, Appelman Y, Mannaerts HFJ, van Dantzig JM, van den Heuvel M, El FM, Rensing BJWM, Ernst NMSK, Dekker IMC, den Hartog FR, Oosterhof T, Lagerweij GR, Buijs EM, van Hessen MWJ, Landman MAJ, van Kimmenade RRJ, Cozijnsen L, Bucx JJJ, van Ofwegen-Hanekamp CEE, Cramer MJ, Six AJ, Doevendans PA, Hoes AW. Effect of using the HEART score in patients with chest pain in the emergency department: a Stepped-Wedge, Cluster randomized trial. Ann Intern Med. 2017;166:689–97.

    Article  Google Scholar 

  26. Visser A, Wolthuis A, Breedveld R, Ter AE. HEART score and clinical gestalt have similar diagnostic accuracy for diagnosing ACS in an unselected population of patients with chest pain presenting in the ED. Emerg Med J. 2015;32:595–600.

    Article  Google Scholar 

  27. Wang G, Zheng W, Wu S, Ma J, Zhang H, Zheng J, Wang J, Xu F, Chen Y. Comparison of usual care and the HEART score for effectively and safely discharging patients with low-risk chest pain in the emergency department: would the score always help? Clin Cardiol. 2020;43:371–8.

    Article  Google Scholar 

  28. Crim MT, Berkowitz SA, Saheed M, Miller J, Deutschendorf A, Gerstenblith G, Hill P, Korley FK. Novel emergency department risk score discriminates acute coronary syndrome among chest pain patients with known coronary artery disease. Crit Pathw Cardiol. 2016;15:138–44.

    Article  Google Scholar 

  29. Zheng W, Ma J, Wu S, Wang G, Zhang H, Zheng J, Xu F, Wang J, Chen Y. Effective combination of isolated symptom variables to help stratifying acute undifferentiated chest pain in the emergency department. Clin Cardiol. 2019;42:467–75.

    Article  Google Scholar 

  30. Del Velasco CS, Anton LA, Gomez SV, Onaindia-Gandarias JJ, de Cacicedo-Fernandez BA, Rodriguez SI, Laraudogoitia ZE. Influence of cardiovascular risk in the prediction and timing of cardiac events after exercise echocardiogram testing without ischemia. Rev Esp Cardiol (Engl Ed). 2017;70:736–43.

    Article  Google Scholar 

  31. Napoli AM, Baird J, Tran S, Wang J. Low adverse event rates but high emergency department utilization in chest pain patients treated in an emergency department observation unit. Crit Pathw Cardiol. 2017;16:15–21.

    Article  Google Scholar 

  32. Bandstein N, Ljung R, Holzmann MJ. Risk of revisits to the emergency department in admitted versus discharged patients with chest pain but without myocardial infarction in relation to high-sensitivity cardiac troponin T levels. Int J Cardiol. 2016;203:341–6.

    Article  Google Scholar 

  33. Khormaee S, Choe J, Ruzbarsky JJ, Agarwal KN, Blanco JS, Doyle SM, Dodwell ER. The fragility of statistically significant results in pediatric orthopaedic randomized controlled trials as quantified by the fragility index: a systematic review. J Pediatr Orthop. 2018;38:e418–23.

    Article  Google Scholar 

  34. Walsh M, Srinathan SK, McAuley DF, Mrkobrada M, Levine O, Ribic C, Molnar AO, Dattani ND, Burke A, Guyatt G, Thabane L, Walter SD, Pogue J, Devereaux PJ. The statistical significance of randomized controlled trial results is frequently fragile: a case for a Fragility Index. J Clin Epidemiol. 2014;67:622–8.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Emergency Medicine, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX, 76104, USA

    Chet D. Schrader, Stefan H. Meyering, Naomi Alanis, James P. D’Etienne, Vietvuong Vo & Hao Wang

  2. Department of Cardiology, JPS Health Network, 1500 S. Main St., Fort Worth, TX, 76104, USA

    Darren Kumar & Ankur R. Kamaria

  3. Department of Information Technology, JPS Health Network, 1500 S. Main St., Fort Worth, TX, 76104, USA

    Sajid Shaikh

  4. University of North Texas Health Science Center, 3500 Camp Bowie Blvd, Fort Worth, TX, 76107, USA

    Nicole Huettner

Authors
  1. Chet D. Schrader
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Stefan H. Meyering
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Darren Kumar
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Naomi Alanis
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. James P. D’Etienne
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Sajid Shaikh
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Vietvuong Vo
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Ankur R. Kamaria
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Nicole Huettner
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Hao Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hao Wang.

Ethics declarations

Acknowledgements

We thank Dr. Amy Ho, a professional English writer, for her dedicated grammatical and language editing.

Funding

None.

Conflicts of interest

The authors declare that they have no conflict of interest.

Ethics approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the University of North Texas Health Science Center Regional Institutional Review Board (Date: 1-16-2020, No. 2020-004).

Consent to participate

This study was approved by local Institutional Review Board with the approval of waived inform consent of the subjects.

Consent for publication

N/A.

Availability of data and materials

Data is available upon request to the corresponding author.

Code availability

N/A.

Authors' contributions

CDS, SM, DK, and HW conceived the research and designed the study. SS, NA, VV, AK, NH, and HW performed data collection. CDS, SM, NA, JPD, and HW performed analysis. CDS, SM, NA, and HW drafted the manuscript. CDS, SM, DK, NA, JPD, and HW contributed to data interpretation, critical review, and revisions of the manuscript for important intellectual content. All authors approved the final version of the submitted manuscript and agree to be accountable for all aspects of the work.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 14 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Schrader, C.D., Meyering, S.H., Kumar, D. et al. The Role of Using HEART Score to Risk Stratify Chest Pain Among Emergency Department High Utilizers. High Blood Press Cardiovasc Prev 28, 69–78 (2021). https://doi.org/10.1007/s40292-020-00426-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40292-020-00426-6

Keywords

Search

Navigation