Clinically relevant adverse cardiovascular events in intermediate heart score patients admitted to the hospital following a negative emergency department evaluation

Rapid outpatient evaluation for emergency department patients with intermediate risk chest pain safely reduces admissions

Objective

This study aims to assess the safety of an outpatient chest pain pathway (OCPP) for patients presenting to the emergency department (ED) with chest pain and a HEART score of 4 or 5.

Methods

This is a retrospective, observational, non-inferiority study assessing the impact of the OCPP on the management and outcomes of ED patients with HEART score of 4 or 5. The study compared patients evaluated in the pre-OCPP (January‒May 2018) and the post-OCPP period (January‒October 2022). Data were collected via non-blinded chart review. The primary outcome was the rate of acute myocardial infarction (AMI) and death in patients utilizing the OCPP compared to patients with HEART score 4 or 5 in 2018. Secondary outcomes included admission rates before and after the implementation of this pathway. Non-inferiority of the post-intervention study epoch for the AMI/death composite outcome was assessed via the two one-sided tests (TOST), procedure.

Results

After implementing the OCPP, rates of patients with ED HEART score of 4 or 5 admitted from the ED decreased from 85.1% (605/711) to 74.1% (1239/1671) in 2022. Of the 432 total patients discharged in 2022, 237 (54.6%) patients were referred to emergent cardiology follow-up via the OCPP. The 30-day rate of AMI/death for patients discharged via the OCPP was 0.4% (1/237), as compared to 2.2% (8/368) in 2018. When compared to rates of AMI/death for all patients with HEART score 4 or 5 in 2018, outcomes for OCPP patients were found to be non-inferior.

Conclusion

The OCPP resulted in non-inferior rates of AMI/death in patients with HEART scores of 4 or 5 as compared to usual care.

Assessing risk of major adverse cardiac event among COVID-19 patients using HEART score

Coronavirus disease 2019 (COVID-19) is known to be associated with cardiovascular complications, but whether the current validated HEART score for chest pain is still applicable for these patients is unknown. This study aims to identify the impact and association of COVID-19 co-infection in patients presenting with chest pain and a calculated HEART score to the emergency departments (ED) with 30-day of major adverse cardiac event (MACE). This is a multicenter, retrospective observational study that included adult (age ≥ 18 years) patients visiting 13 different EDs with chest pain and evaluated using a HEART score. The primary outcome was the percentage of 30-day MACE, which included acute myocardial infarction, emergency percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or death among patients who presented with chest pain and had COVID-19 co-infection. The sensitivity and specificity of the HEART score among COVID-19 co-infection for MACE were assessed by the receiver operating curve (ROC). We analyzed records of 46,210 eligible patients, in which 327 (0.7%) patients were identified as infected with COVID-19. Patients with COVID-19 had higher mean total HEART score of 3.3 (1.7), compared to patients who did not have COVID-19 (3.1, SD 1.8, P = 0.048). The rate of MACE was similar between both groups. There were only 2 (0.6%) COVID-19 patients who had MACE, compared to 504 (1.1%) patients in control group. Total HEART score was associated with an area under the ROC (AUROC) of 0.99, while the control group's was 0.78. History was associated with high AUROC in both COVID-19 (0.74) and control groups (0.76). Older age in COVID-19 had higher AUROC (0.89) than control patients (0.63). Among patients presenting to the ED with chest pain and having COVID-19 infection, HEART score had predictive capability for MACE, similar to patients without COVID-19 infection. Further studies with more COVID-19 patients are still necessary to confirm our observation.

Multicenter analysis to assess risk of major adverse cardiac events in patients undergoing high-sensitivity troponin testing in the emergency department

Study hypothesis

Our objective was to evaluate 30-day major adverse cardiac events (MACE) in emergency department (ED) patients with normal high-sensitivity troponins (hs-trop). We hypothesized that MACE rates would be <1% in patients with (1) two normal troponins regardless of change in troponin (delta) and (2) index hs-trop below the limit of quantitation (LOQ) regardless of the institution modified HEART score.

Methods

This was a multicenter, retrospective, cohort study of adult patients who presented to 1 of 18 EDs between July 2020 and April 2021 with acute coronary syndrome as defined by an institutional-modified HEART score completed by their treating physician or midlevel, no evidence of ST-elevation myocardial infarction, and an index or serial gender-adjusted hs-trop within normal limits. The primary outcome was MACE within 30 days of index ED encounter. A detailed case review was then performed for those patients experiencing a MACE.

Results

Of the 9084 patients who had single or serial normal troponins, 31 (0.34%; confidence interval [CI] 0.23%-0.48%) experienced MACE. Of the 6140 patients with 2 normal hs-trop and a delta (change in troponin) <4, 27 patients (0.44%; CI 0.29%-0.64%) experienced MACE. Only 1 of the 69 patients with 2 normal hs-trop results but delta (change in troponin) ≥ 4 (1.45%; CI 0.04%-7.81%) suffered MACE. This patient was classified as non-low risk by our institutional HEART score. Of 7498 patients with an index hs-trop 

Conclusion

Patients with 2 normal hs-trop values in the ED are unlikely to suffer 30-day MACE. Although it remains unclear whether patients with delta (change in troponin) ≥4 despite normal troponins will have a 30-day MACE, this situation is rare. Additionally, a single index hs-trop <6 ng/L demonstrated a low risk for 30-day MACE independent of the institutional HEART score.

Collapse

Key Words Collapse

MESH Headings Collapse

Grants Collapse

Affiliation(s)

Victoria Serven Department of Emergency MedicineAtrium Health's Carolinas Medical CenterCharlotteNorth CarolinaUSA
Kamala Swayampakala Sanger Heart & Vascular InstituteAtrium HealthCharlotteNorth CarolinaUSA
Christy Lesassier Sanger Heart & Vascular InstituteAtrium HealthCharlotteNorth CarolinaUSA
Tyler Siekmann Department of Emergency MedicineAtrium Health's Carolinas Medical CenterCharlotteNorth CarolinaUSA
Gabriel Rivera‐Camacho Department of Emergency MedicineAtrium Health's Carolinas Medical CenterCharlotteNorth CarolinaUSA
Santosh Rao Sanger Heart & Vascular InstituteAtrium HealthCharlotteNorth CarolinaUSA
David Matthew Sullivan Information and Analytics ServicesAtrium HealthCharlotteNorth CarolinaUSA
Harvey Pendell Meyers Department of Emergency MedicineAtrium Health's Carolinas Medical CenterCharlotteNorth CarolinaUSA
David Pearson Department of Emergency MedicineAtrium Health's Carolinas Medical CenterCharlotteNorth CarolinaUSA

Collapse

Predictive Value of the HEART Score Combined with Hypersensitive C-Reactive Protein for 30 d Adverse Cardiovascular Events in Patients with Acute Chest Pain

Purpose

This study aimed to explore the predictive value of the HEART score combined with hypersensitive C-reactive protein (hs-CRP) for 30 d major adverse cardiovascular events (MACEs) in patients with acute chest pain.

Methods

103 patients with acute chest pain admitted to the emergency department of our hospital from May 2020 to May 2022 were selected as the study subjects. The patients' HEART score and plasma hs-CRP level were recorded. The patients were followed up for 30 d to observe whether MACE occurred.

Results

Among 103 patients with acute chest pain, MACE occurred in 8 cases within 30 d of follow-up, and the probability of MACE was 7.76%. There was a statistically significant difference in 30 d MACE risk among patients with different HEART score stratification (P < 0.05). The age, HEART score, and hs-CRP levels of patients in the MACE group were higher than those in the non-MACE group (P < 0.05). The HEART score and the hs-CRP level were independent risk factors for 30 d MACE in patients with acute chest pain (P < 0.05). The AUC of the HEART score combined with hs-CRP in the occurrence of 30 d MACE in patients with acute chest pain was 0.901, which was significantly higher than 0.720 and 0.758 of single detection.

Conclusion

The HEART score combined with hs-CRP can better predict the occurrence of 30 d MACE in patients with acute chest pain.

Can ED chest pain patients with intermediate HEART scores be managed as outpatients?

PURPOSE

Current guidelines recommend hospital admission for patients who present to the emergency department (ED) with chest pain and are scored as intermediate risk for adverse outcomes based on the HEART score. While hospital admission for these patients allows for timely investigation and treatment, it is a resource-intensive process. This study examines whether intermediate HEART score patients can be safely managed on an outpatient basis through rapid access chest pain clinics.

METHODS

This retrospective observational study included all ED chest pain patients referred to rapid access clinics from January 2018 to April 2020 in Regina and Saskatoon, Saskatchewan. ED physician HEART scores were used in lieu of reviewer HEART scores when available. The primary outcome was the rate of major adverse coronary events (MACE), a composite measure of death, acute coronary syndrome, stroke, coronary angiography, and revascularization at 6 weeks in intermediate-risk patients. Secondary outcomes were the type of MACE, rate of MACE before rapid access clinic appointment and the most predictive component of the HEART score.

RESULTS

There were 1989 ED referrals, of which 817 were for intermediate-risk patients. 9.3% of intermediate-risk patients had a MACE at 6 weeks. MACE occurred before rapid access clinic follow-up in 1.1% of intermediate-risk patients, with coronary angiography being the most common MACE. Excluding coronary angiography, the risk of MACE before rapid access clinic follow-up was 0.7% in intermediate-risk patients. Components of the HEART score most predictive of MACE were troponin (OR 11.0, 95% CI: 3.7-32.3) and history (5.3, 95% CI: 2.4-11.8).

CONCLUSION

This study demonstrates that rapid access clinics are likely a safe alternative to admission for intermediate-risk chest pain patients and could reduce costly inpatient admissions for chest pain. With angiography excluded, MACE rates were well below the American College of Emergency Physicians cited 2% threshold.

Role of HEART score in prediction of coronary artery disease and major adverse cardiac events in patients presenting with chest pain

Introduction. Chest pain (CP) diagnostics accuracy remains debatable for both general practitioners (GP) or emergency department (ED) physicians for patients in HEART score (HS) low- and intermediate-risk groups which prompted us to review our electronic database for all patients admitted via our center?s ED during 2014 to 2020 for CP and suspect acute coronary syndrome. Methods. Patients were divided in function of low- or intermediate-risk HS and assessed during a three month follow up for angiogram results, MACE, lab results and echo parameters. Results. Of 585 patients included, low-risk HS group (21,4%, 36% were women) had significant coronary disease on angiogram in 68%, while for intermediate-risk HS group (78.6%, with 32.6% women) it was for 18.4% of patients (p < 0,0005). Area under the ROC curve of HS in detecting patients with ischemic heart disease as a cause of CP was 0.771 (95% CI:0.772-0.820) with best cut-off point HS was calculated at 3.5. Sensitivity and specificity were 89.2% and 57.6% respectively. Adjusting for sex, lab results and HS, AUROC curve of this model was 0.828 (95% CI:0.786-0.869; p < 0,0005) with cut-off of 77.95. Sensitivity and specificity were 84,9% and 68% respectively. In the three-month follow-up post-discharge, there was a significant difference in MACE between groups (low-vs. intermediate-risk HS was 3.4 vs. 16.7% p < 0.05). Conclusion. HS for our CP patients admitted via our ED by GP and ED physicians? referral, provides a quick and reliable prediction of ischemic heart disease and MACE.