Divided HEART - EM and Cardiology Disagree

Short Attention Span Summary

Divided HEART
The subjective part of the HEART score is the bit about the history and whether or not you think it is suspicious for ACS.  In these 33 patients, 70% had a discrepancy between the cardiologist's HEART score and the emergency physician's HEART score.  The cardiologist was more likely to say the history was not suspicious, and the emergency physician was likely to say it was.

Spoon Feed
Your HEART score calculation and that of your friendly neighborhood cardiologist are not the same.  You are more suspicious than the cardiologist that the history is concerning for ACS.  It's important to know our biases and err in a way the patient suffers the least (to quote Corey Slovis).


Abstract

Am J Emerg Med. 2017 Jan;35(1):132-135. doi: 10.1016/j.ajem.2016.09.058. Epub 2016 Sep 28.

Documentation of HEART score discordance between emergency physician and cardiologist evaluations of ED patients with chest pain.

Wu WK1, Yiadom MY2, Collins SP3, Self WH4, Monahan K5.

Author information:

1Vanderbilt University School of Medicine, Nashville, TN. Electronic address: w.kelly.wu@vanderbilt.edu.

2Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN. Electronic address: maya.yiadom@vanderbilt.edu.

3Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN. Electronic address: sean.collins@vanderbilt.edu.

4Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN. Electronic address: wesley.self@vanderbilt.edu.

5Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN. Electronic address: ken.monahan@vanderbilt.edu.

Abstract

INTRODUCTION:

A triage cardiology program, in which cardiologists provide consultation to the Emergency Department (ED), may safely reduce admissions. For patients with chest pain, the HEART Pathway may obviate the need for cardiology involvement, unless there is a difference between ED and cardiology assessments. Therefore, in a cohort concurrently evaluated by both specialties, we analyzed discordance between ED and cardiology HEART scores.

METHODS:

We performed a single-center, cross-sectional, retrospective study of adults presenting to the ED with chest pain who had a documented bedside evaluation by a triage cardiologist. Separate ED and cardiology HEART scores were computed based on documentation by the respective physicians. Discrepancies in HEART score between ED physicians and cardiologists were quantified using Cohen κ coefficient.

RESULTS:

Thirty-three patients underwent concurrent ED physician and cardiologist evaluation. Twenty-three patients (70%) had discordant HEART scores (κ = 0.13; 95% confidence interval, -0.02 to 0.32). Discrepancies in the description of patients' chest pain were the most common source of discordance and were present in more than 50% of cases. HEART scores calculated by ED physicians tended to overestimate the scores calculated by cardiologists. When categorized into low-risk or high-risk by the HEART Pathway, more than 25% of patients were classified as high risk by the ED physician, but low risk by the cardiologist.

CONCLUSION:

There is substantial discordance in HEART scores between ED physicians and cardiologists. A triage cardiology system may help refine risk stratification of patients presenting to the ED with chest pain, even when the HEART Pathway tool is used.

Copyright © 2016 Elsevier Inc. All rights reserved.

PMID: 27745728 [PubMed - in process]

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