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HEART – Can We Agree on the Score?

November 7, 2018

Written by Clay Smith

Spoon Feed
Interoperator reliability was high among various paired users of the HEART score.  This means people with different levels and types of training were likely to score it the same.

Why does this matter?
The HEART score and HEART Pathway are helpful tools to identify patients with very low risk of acute coronary syndrome (ACS) who may be safely discharged home.  But if your HEART score is a 4 and mine is a 3, then that makes a difference in disposition – more testing vs discharge home.  Interoperator reliability has been assessed retrospectively in the past.  This is a prospective look.

HEARTs beating together
This was a prospective study of paired scorers of patients in the ED with possible ACS: senior doctor/junior doctor or senior nurse/junior nurse.  All had a pocket score card guide as a memory aid.  They found that in 88 patient/scoring pairs that the intraclass correlation coefficient (ICC) was high overall, 0.91 (that’s excellent, very high agreement).  This suggests that the, “HEART Score is reproducible when used by different professional groups and grade of clinician.”

For the individual components, the ICC for troponin and age were 1, which means 100% agreement.  ICC for history was 0.41; ECG, 0.64; and risk factors, 0.84.  They initially planned to enroll 120 patients but were unable to do so.  However, the result was still significant, as reliability was higher than expected.  They also used high-sensitivity troponin, which may differ from place to place.  History had the lowest interoperator reliability.  As this study shows, deciding what is or is not “suspicious” for ACS in the history is tough.

Another Spoonful
Using the HEART Pathway App has helped me, especially when scoring the “History” portion of the HEART score.

Do all HEART Scores beat the same: evaluating the interoperator reliability of the HEART Score.  Emerg Med J. 2018 Sep 14. pii: emermed-2018-207540. doi: 10.1136/emermed-2018-207540. [Epub ahead of print]

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What are your thoughts?