HEART and TIMI Scores Predict Severe Coronary Atherosclerosis in Patients With End-Stage Renal Disease

Objectives History, EKG, age, risk factors, and troponin (HEART) and thrombolysis in myocardial infarction (TIMI) risk calculators have been validated to predict the risk of subsequent acute coronary syndromes and in some studies, severe coronary atherosclerosis in patients with a concerning clinical history. Their performance in patients with end-stage renal disease (ESRD), a population with a high pretest probability for the condition, is unknown. We aimed to determine whether HEART and TIMI scores can predict severe coronary atherosclerosis in patients with end-stage renal disease (ESRD). Methods A single-center retrospective cohort of admitted patients aged 18 years or older with ESRD on dialysis who underwent coronary angiography during admission (November 2010 to December 2017) was retrospectively reviewed. The outcome of coronary angiography was compared with the calculated HEART and TIMI scores at the time of presentation. Receiver operating characteristics and logistic regression models were used to determine optimal score cutoffs, score usefulness, and associations between outcomes, scores, and patient characteristics. Results Among 231 patient encounters, the mean HEART and TIMI scores were 6±2 and 3±1 points, respectively. Patients with diabetes mellitus, those 65 years old and older, and those reported to have angina pectoris were more likely to show severe coronary artery disease (CAD) lesions. Optimal score cutoffs for determining severe coronary lesions were between six and seven (area under the curve (AUC)=0.754, confidence interval (CI): 0.682-0.826) and between three and four (AUC=0.716, CI: 0.640-0.792) for the HEART and TIMI scores, respectively. Conclusion Similar to the general population, HEART and TIMI scores can predict severe coronary atherosclerosis in the complex ESRD population.

Association between history of cancer and major adverse cardiovascular events in patients with chest pain presenting to the emergency department: a secondary analysis of a prospective cohort study

OBJECTIVES

Cancer survivorship status among patients evaluated for chest pain at the emergency department (ED) warrants high degree of suspicion. However, it remains unclear whether cancer survivorship is associated with different risk of major adverse cardiac events (MACE) compared to those with no history of cancer. Furthermore, while HEART score is widely used in ED evaluation, it is unclear whether it can adequately triage chest pain events in cancer survivors. We sought to compare the rate of MACE in patients with a recent history of cancer in remission evaluated for acute chest pain at the ED to those with no history of cancer, and compare the performance of a common chest pain risk stratification score (HEART) between the two groups.

METHODS

We performed a secondary analysis of a prospective observational cohort study of chest pain patients presenting to the EDs of three tertiary care hospitals in the USA. Cancer survivorship status, HEART scores, and the presence of MACE within 30 days of admission were retrospectively adjudicated from the charts. We defined patients with recent history of cancer in remission as those with a past history of cancer of less than 10 years, and currently cured or in remission.

RESULTS

The sample included 750 patients (age: 59 ± 17; 42% females, 40% Black), while 69 patients (9.1%) had recent history of cancer in remission. A cancer in remission status was associated with a higher comorbidity burden, older age, and female sex. There was no difference in risk of MACE between those with a cancer in remission and their counterparts in both univariate [17.4 vs. 19.5%, odds ratio (OR) = 0.87 (95% confidence interval (CI), 0.45-1.66], P = 0.67] and multivariable analysis adjusting for demographics and comorbidities [OR = 0.62 (95% CI, 0.31-1.25), P = 0.18]. Patients with cancer in remission had higher HEART score (4.6 ± 1.8 vs. 3.9 ± 2.0, P = 0.006), and a higher proportion triaged as intermediate risk [68 vs. 56%, OR = 1.67 (95% CI, 1.00-2.84), P = 0.05]; however, no difference in the performance of HEART score existed between the groups (area under the curve = 0.86 vs. 0.84, P = 0.76).

CONCLUSIONS

There was no difference in rate of MACE between those with recent history of cancer in remission compared to their counterparts. A higher proportion of patients with cancer in remission was triaged as intermediate risk by the HEART score, but we found no difference in the performance of the HEART score between the groups.

HEART Score of Four for Age and Risk Factors: A Case Series

Chest pain is a frequent chief complaint in the ED. Identifying acute coronary syndrome (ACS) and establishing proper disposition for further risk assessment for major adverse cardiac events are paramount. The HEART Score is a key decision-making tool used to determine patient risk and disposition. One scenario with a potential drawback of the HEART Score is found in patients with a score of four based solely on age and risk factors. The HEART Score categorizes a score of three or less as low risk, and patients with scores above this threshold are typically admitted. We present six cases of chest pain presenting to a military emergency department with a score of four based solely on age and risk factors. They represent every such case found in a previously created database used to validate the HEART Score. We followed each case forward one year in electronic medical records to identify major adverse cardiac events. With the exception of one case that was placed on hospice for non-cardiac reasons and subsequently lost to follow up, there were no adverse events. There is a rising concern for increasing hospital admission rates, overuse of resources, and cost. We highlight that this subset of HEART Score patients requires a more nuanced risk stratification in the ED. It may be worth the time and effort to risk stratify this subset with coronary computed tomography angiography. This additional effort may help reduce admission at such a patient's current and future presentations to the ED for chest pain.

The HEART score is useful to predict cardiovascular risks and reduces unnecessary cardiac imaging in low-risk patients with acute chest pain

The present study was to investigate whether the HEART score can be used to evaluate cardiovascular risks and reduce unnecessary cardiac imaging in China.Acute coronary syndrome patients with the thrombosis in myocardial infarction risk score < 2 were enrolled in the emergency department. Baseline data were collected and a HEART score was determined in each participant during the indexed emergency visit. Participants were follow-up for 30 days after discharge and the studied endpoints included acute myocardial infarction, cardiovascular mortality and all-cause mortality.A total of 244 patients were enrolled and 2 was loss of follow-up. The mean age was 50.4 years old and male patients accounted for 64.5%. Substernal pain and featured as pressure of the pain accounted for 34.3% and 39.3%, respectively. After 30 days' follow-up, no patient in the low-risk HEART score group and 2 patients (1.5%) in the high risk HEART score group had cardiovascular events. The sensitivity of HEART score to predict cardiovascular events was 100% and the specificity was 46.7%. The potential unnecessary cardiac testing was 46.3%. Cox proportional hazards regression analysis showed that per one category increase of the HEART score was associated with nearly 1.3-fold risk of cardiovascular events.In the low-risk acute chest pain patients, the HEART score is useful to physicians in evaluating the risk of cardiovascular events within the first 30 days. In addition, the HEART score is also useful in reducing the unnecessary cardiac imaging.