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External validation of a low HEAR score to identify emergency department chest pain patients at very low risk of major adverse cardiac events without troponin testing

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A Correction to this article was published on 25 March 2024

This article has been updated

Abstract

Background

The history, ECG, age, risk factor (HEAR) score has been proposed to identify patients at sufficiently low risk of acute coronary syndrome that they may not require troponin testing. The objective of this study was to externally validate a low HEAR score to identify emergency department (ED) patients with chest pain at very low risk of 30-day major adverse cardiac events (MACE).

Methods

This was a secondary analysis of a prospective cohort of patients requiring troponin testing to rule out myocardial infarction (MI) in a large urban ED. HEAR scores were calculated in two cohorts: (1) patients with no known history of coronary artery disease (CAD); and (2) all eligible patients. The proportion of patients classified as very low risk, sensitivity, specificity, predictive values and likelihood ratios at each cut-off were quantified for index acute myocardial infarction (AMI) and 30-day MACE at HEAR = 0 and HEAR ≤ 1 thresholds.

Results

Of the 1150 patients included in this study, 820 (71.3%) had no history of CAD, 97 (8.4%) had index AMI and 123 (10.7%) had 30-day MACE. In patients with no prior history of CAD, HEAR ≤ 1 identified 202 (24.6%) of patients as very low risk for 30-day MACE with 98.4% (95% CI 91.6–99.9%) sensitivity. Among all patients, HEAR ≤ 1 identified 202 (17.6%) patients as very low risk for 30-day MACE with 99.2% (95% CI 95.6–99.9%) sensitivity.

Conclusions

A HEAR score ≤ 1 can identify more than 17% of all patients as very low risk for index AMI and 30-day MACE and unlikely to benefit from troponin testing. Broad implementation of this strategy could lead to significant resource savings.

Résumé

Contexte

Le score HEAR (History, ECG, Age, Risk Factor) a été proposé pour identifier les patients présentant un risque suffisamment faible de syndrome coronarien aigu pour ne pas nécessiter de test à la troponine. L’objectif de cette étude était de valider à l’externe un faible score HEAR afin d’identifier les patients du service d’urgence (DE) souffrant de douleurs thoraciques à très faible risque d’événements cardiaques indésirables majeurs (MACE) de 30 jours.

Méthodes

Il s'agissait d'une analyse secondaire d'une cohorte prospective de patients nécessitant un test à la troponine pour exclure un infarctus du myocarde (IM) dans un grand service d'urgence urbain. Les scores HEAR ont été calculés dans deux cohortes : (1) les patients sans antécédents connus de maladie coronarienne (MC) ; et (2) tous les patients éligibles. La proportion de patients classés à très faible risque, la sensibilité, la spécificité, les valeurs prédictives et les rapports de vraisemblance à chaque seuil ont été quantifiés pour l'infarctus aigu du myocarde (IAM) de l'index et la MACE à 30 jours aux seuils HEAR = 0 et HEAR ≤ 1.

Résultats

Sur les 1 150 patients inclus dans cette étude, 820 (71.3%) n'avaient pas d'antécédents de coronaropathie, 97 (8.4%) avaient un IAM index et 123 (10.7%) avaient une MACE à 30 jours. Chez les patients sans antécédents de coronaropathie, HEAR ≤ 1 a identifié 202 (24,6%) des patients comme présentant un très faible risque de MACE à 30 jours avec une sensibilité de 98.4% (IC 95% 91.6–99.9%). Parmi tous les patients, HEAR ≤ 1 a identifié 202 (17.6%) patients comme présentant un très faible risque de MACE à 30 jours avec une sensibilité de 99.2% (IC 95% 95.6–99.9%).

Conclusions

Un score HEAR ≤ 1 peut identifier plus de 17% de tous les patients comme étant à très faible risque d'IAM d'index et de MACE à 30 jours et peu susceptibles de bénéficier d'un test à la troponine. La mise en œuvre à grande envergure de cette stratégie pourrait permettre de réaliser d’importantes économies de ressources.

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Funding

The parent study was funded by an investigator initiated, non-restricted research grant from Roche Diagnostics Canada.

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Authors and Affiliations

  1. Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, 3280 Hospital Drive NW, Room 3E34, Calgary, AB, T2N 4Z6, Canada

    Connor M. O’Rielly, James E. Andruchow & Andrew D. McRae

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  1. Connor M. O’Rielly
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  2. James E. Andruchow
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  3. Andrew D. McRae
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the Network of Canadian Emergency Researchers

Corresponding author

Correspondence to Andrew D. McRae.

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All authors declare that they have no conflict of interest.

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The original online version of this article was revised: Authorship correction.

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O’Rielly, C.M., Andruchow, J.E., McRae, A.D. et al. External validation of a low HEAR score to identify emergency department chest pain patients at very low risk of major adverse cardiac events without troponin testing. Can J Emerg Med 24, 68–74 (2022). https://doi.org/10.1007/s43678-021-00159-y

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