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Using the HEART Score for Chest Pain in the Urgent Care

Corey Slovis, MD, Mizuho Morrison, DO, Heidi James, MD, and Andrew Buelt, DO
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15:43

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The heart score is gaining popularity in the emergency medicine and cardiology worlds to risk stratify patients for ACS. Mizuho, Mike and friends discuss the basics of the heart score and its potential utility in the UC.

 

Pearls:

  • The HEART score offers an opportunity for those of us in acute care settings including the Urgent Care (UC) to coalesce around a single vehicle that is relatively intuitive and allow us to identify enough low risk patients to send home on a consistent basis.

  • Not all the variables and risk factors used in the HEART score calculation are equally important and it is critical for providers to weigh this information as well as their gestalt when deciding the appropriate plan for patients.  The HEART score should not be used as an algorithm to be followed blindly.  

 

  • Chest pain is always a challenging chief complaint regardless of the clinical setting, but when it presents to the Urgent Care there are added challenges given the lack of available lab testing, imaging and many other variables.  Very often patients who present to the UC with chest pain get sent to the ED immediately.  

  • The HEART Score is a new risk stratification decision tool, and as more UCs adopt point-of-care troponin testing, the two combined may allow for a more complete evaluation and disposition of some chest pain patients from the UC.

  • Until just a few years ago, provider relied solely on their gestalt to decide which chest pain patients were at higher or lower risk, who needed a stress test vs admission, etc.  The HEART score provides an objective scoring system based on 5 variables that allows providers to make an informed decision about who needs to be admitted, who needs to be stressed, and who is okay for discharge from the ED with referral back to their PMD or cardiologist to consider outpatient stress testing.  

  • Six AJ, et al. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008;16:191–196.  PMID PMC2442661

    • The HEART score is a prospectively studied scoring system to help acute care providers with access to troponin assays risk stratify chest pain patients and ultimately help predict who may be at high risk for having a major adverse cardiac event (MACE) within the next 6 weeks.  Each of the 5 variables is scored 0, 1 or 2 depending on the level of concern.  

H

History

Slightly suspicious = 0

Moderately suspicious = 1

Highly suspicious = 2

E

EKG

Normal = 0

Non-specific repolarization changes = 1

Significant ST depression = 2

A

Age

<45 = 0

45-65 = 1

>65 = 2

R

Risk factors

No risk factors = 0

1-2 risk factors = 1

3+ risk factors = 2


Risk Factors: hypercholesterolemia, hypertension, diabetes, smoking, family history of cardiac disease, obesity.

T

Troponin*

Normal = 0

1-3x normal = 1

>3x normal = 2

* Not all troponins are created equally and the sensitivity of your institution’s troponin assay should be considered.

 

HEART Score

Risk

0-3

Low risk

>4

Higher risk

 

  • Dr. Slovis describes that his practice is to risk stratify the HEART score into 3 groups:

    • Low risk 0-2

    • Moderate risk 3-4

    • High risk >5

    • In addition, he notes that not all risk factors are equal.  For example:

      • ANY elevated troponin, particularly in the setting of a patient presenting with chest pain, deserves further work up.  

      • A patient with a very ischemic looking EKG should be admitted for further work up, regardless of their HEART score.  

      • A highly suspicious history should be listened to.  This is your gestalt and it still matters.  

      • Pay attention to the risk factors.  A family history of MI in people in their 40s, or smokers with diabetes should scare you.  

 

  • Recommendations for using the HEART score appropriately:

    • Know your troponin.  There are multiple different troponin assays with different values for normal.  Every physician needs to know what generation assay they are using, what the abnormal value is and how soon it turns positive (the ultra-high sensitivity troponins are positive within 1 hour.  These are being used in Europe, but not in the US).  Most troponins in the US change within 2-3 hours.  The current American Heart Association recommendations are a 0 and 3 hour repeat and this was the same time frame used in the HEART score study.  

      • If a patient has had chest pain or has been asymptomatic for 3+ hours, one troponin is sufficient.  

    • Time is of the essence with chest pain.  If the patient is actively having chest pain, you cannot discharge them without a clear explanation for the pain.  

    • Follow up recommendations.  If a patient scores as low risk and you discharge them home, the American Heart Association recommends referral for stress testing within 3 days.  In most systems, though, this does not happen.  

      • Amsterdam EA,  et al; American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Interdisciplinary Council on Quality of Care and Outcomes Research. Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation. 2010;122(17):1756-1776. PMID: 20660809

    • Use the HEART score in addition to your clinical judgement.  Do not use the HEART score as the single algorithm that you use to evaluate chest pain.  Calculate it, carefully study the EKG, use your gestalt, and talk with the patient to make the decision together.  Give the patient patient the numbers and the choice: do they want to stay for more tests, do they want to follow up with their PMD, do they want a stress test now or later this week?  

 

  • There is more to come.  The HEART score has been validated by 2 separate studies but is still in its infancy and is undergoing much more validation.  In the coming years we will know more about how and when to use it, and which patients should fall out of the pathway.  

    • Six AJ, et al. The HEART Score for the Assessment of Patients With Chest Pain in the Emergency Department. A Multinational Validation Study. Crit Pathways in Cardiol 2013;12: 121–126. PMID 23892941

Backus BE, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013 Oct 3;168(3):2153-8. PMID: 23465250

Ian L., Dr -

For mine HEAART ought be more sensitive where the extra A is atypical that is non classical features .Especially in elderly over80 Diabeticsand Women the Classic chest pain crushing or tight with diaphoresis radiation from sternal area to the right or left or both sides vomiting for MI and tightness on exertion for angina relief by rest is replaced by :Shortness of breath extra fatigue and not chest pain but pain in only the jaw hands inter scapular area considering these symptoms because misses derive from that subset and therefore we need memory jolts .

Mike W., MD -

Totally agree - good points - we need to use our brains with this also and not just 'cook book' it!!

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Heart Score, PECARN and A Twist of Lyme Full episode audio for MD edition 175:52 min - 83 MB - M4AHippo Urgent Care RAP July 2016 Summary 549 KB - PDF