the heart score
DESCRIPTION
TIMI, GRACE, PURSUIT, and FRISC risk scores were not developed in an ED population, but the HEART Score evaluates all comers presenting to the ED with chest pain. This is the evidence for the HEART Score.TRANSCRIPT
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The HEART Score: A New ED Chest Pain Assessment Tool
Salim R. Rezaie, MDAssistant Program Director of Emergency Medicine
Assistant Clinical Professor of Emergency Medicine/Internal Medicine
UTHSCSA, San Antonio, TX
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Objectives
Discuss Chest Pain Risk Stratification Tools & Their Limitations
What is the HEART Score?
What is the Evidence for the HEART Score in the ED
Are there other Risk Stratification Scores to Know About
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Disclosures
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Chest Pain Risk Stratification ToolsRisk Score
Year of Publication
Score Range
Score Predicts C-Statistic of Original Study
PURSUIT 2000 1 - 18 Risk of death/MI at 30 days after admission
0.84 (death) and 0.67 (death/MI)
TIMI 2000 0 - 7 Risk of all cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization within 14 days after admission
0.65
GRACE 2003 1 - 372 Risk of hospital death and post-discharge death at 6 months
0.83
FRISC 2004 0 - 7 Treatment effect of early invasive strategies in ACS
0.77 (death) and 0.7 (death/MI)
HEART 2008 0 - 10 Prediction of combined endpoint of MI, PCI, CABG or Death within 6 weeks after presentation
0.9
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C-Statistic
Probability that outcome is better than chance
Range: 0.5 to 1.0
0.5 = no better than chance
1.0 = perfectly identifies those within a group and those not
≥0.7 = Model is reasonable
≥0.8 = Model is strong
Tru
e P
ositi
ve R
ate
False Positive Rate
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Chest Pain Risk Stratification ToolsRisk Score
Year of Publication
Score Range
Score Predicts C-Statistic of Original Study
PURSUIT 2000 1 - 18 Risk of death/MI at 30 days after admission
0.84 (death) and 0.67 (death/MI)
TIMI 2000 0 - 7 Risk of all cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization within 14 days after admission
0.65
GRACE 2003 1 - 372 Risk of hospital death and post-discharge death at 6 months
0.83
FRISC 2004 0 - 7 Treatment effect of early invasive strategies in ACS
0.77 (death) and 0.7 (death/MI)
HEART 2008 0 - 10 Prediction of combined endpoint of MI, PCI, CABG or Death within 6 weeks after presentation
0.9
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PURSUIT Risk Score
NO TROPONIN Included
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GRACE Risk Score
VERY COMPLEX
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FRISC Score
BINARY SCORING SYSTEM
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TIMI Risk Score
BINARY SCORING SYSTEM
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Issues with Risk Scores
Risk Score Weaknesses
PURSUIT • Does not use troponin• Majority of Score Dependent on Patient Age
TIMI • Poor Predictive Power (i.e. c-statistic 0.65)
GRACE • Very Complex to Use• Large Portion of Score Dependent on Patient Age
FRISC • Poor Predictive Power (i.e. c-statistic 0.7)
None evaluated all comers (Only patients with ACS)
None derived for an ED patient population
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What is the HEART Score?
H = History
E = ECG
A = Age
R = Risk Factors
T = Troponin
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What is the Evidence for the HEART Score?
122 patients with CP
Predictive Value of HEART Score out to 3 months
Primary Endpoints:1. AMI
2. PCI
3. CABG
4. DEATH
Six AJ et al. Neth Heart J. 2008. PMCID: PMC2442661
Limitations:1. Pilot study
2. observational and retrospective
3. Single Center
4. Netherlands
5. Only 122 patients
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Analysis
HEART Score
Risk of AMI, PCI, CABG, and/or Death Disposition
0 - 3 1/39 (2.5%) Discharge
4 - 6 12/59 (20.3%) Admission for Clinical Observation
≥7 16/22 (72.7%) Early Invasive Strategies
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External Validation of HEART Score
2440 patients with CP
Multicenter (10 hospitals)
Compared to TIMI & GRACE scores (c-statistic)
Primary Endpoint:1. *Major Adverse
Cardiac Event (MACE) at 6 weeks
Secondary Endpoint:1. AMI and Death
2. ACS
3. PCI
Backus BE et al. International Journal of Cardiology 2013. PMID: 23465250
*AMI, PCI, CABG, & Death
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Analysis
HEART Score Risk of MACE Original Study
0 - 3 1.7% 2.5%
4 - 6 16.6% 20.3%
≥7 50.1% 72.7%
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Other Thoughts
Limitations:1. 45 patients lost to
follow-up
2. Netherlands
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A New Risk Score? EDACS-ADP
Emergency Department Assessment of Chest Pain Score (EDACS) – Identified 6 Predictors
Accelerated Diagnostic Protocol (ADP)
Than M et al. Emergency Medicine Australasia 2014. PMID: 24428678
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What they did…
Develop a Score to predict 30d risk of MACE in ED setting
Develop and Validate a CP risk score + ADP to safely increase patients suitable for early discharge
Identify statistical predictors (37) for MACE
AMI, PCI, CV mortality, ventricular arrhythmia, cardiogenic shock, or high AV block
Use clinician feedback to improve clinical plausibility
Derivation – 1974 patients
Validation – 608 patients
Predictor P Value Odds Ratio
Age <0.0001 1.5 (Per 10 years)
Male <0.0001 2.110
Diaphoresis 0.0038 1.460
Pain radiates to arm (or shoulder)
<0.0001 1.850
Pain on inspiration 0.0190 0.630
Pain on palpation 0.0379 0.470
www.rebelem.com Chest Pain: The Value of a Good History
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AnalysisSensitivity Specificity Identification of Low Risk Patients
for MACE
Derivation 99.0% 49.9% 42.2%
Validation 100% 59.0% 51.3%
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Other Thoughts
Limitations:1. Predominantly
Caucasian, older males
2. Feedback from clinicians was a convenience sample
3. Validation done with phone calls and chart reviews
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Conclusions
TIMI, GRACE, PURSUIT, & FRISC scores evaluate high risk patients (i.e. ACS) & not derived in ED populations
HEART Score is derived in an ED population of all comers with chest pain and superior to TIMI score
Need a US validation study before 100% implementation
Maybe in the pipeline…EDACS-ADP Risk Score
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Bibliography
1. Backus BE et al. A Prospective Validation of the HEART Score for Chest Pain Patients at the Emergency Department. International Journal of Cardiology 2013; 168: 2153 – 58.
2. Backus BE et al. Risk Scores for Patients with Chest Pain: Evaluation in the Emergency Department. Current Cardiology Reviews, 2011; 7: 2 – 8.
3. Six AJ et al. Chest Pain in the Emergency Room: Value of the HEART Score. Neth Heart J 2008;16: 191- 6.
4. Than M et al. Development and Validation of the Emergency Department Assessment of Chest Pain Score and 2h Accelerated Diagnostic Protocol. Emergency Medicine Australasia 2014; 26: 34 – 44.
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Questions?
www.rebelem.com