Written by Clay Smith
The HEART score had high pooled diagnostic accuracy for predicting short term major adverse coronary events (MACE).
Why does this matter?
ACEP stated that a zero miss rate isn’t reasonable, and “the majority of patients and providers would agree that a missed diagnosis rate of 1% to 2%…is acceptable.” The ACEP statement recommended HEART. This analysis pooled studies to see if HEART was the best.
HEART winner in race with itself!
This was a meta-analysis of 29 studies, 42,202 patients, looking at the diagnostic accuracy of the HEART score. They found that a score ≥4 had a sensitivity of 95.9% (95%CI 93.3-97.5) and specificity of 44.6% for MACE. HEART performed better than the TIMI score. The authors favored HEART as the go-to clinical decision instrument for low-risk chest pain.
The editorialist, however, was not convinced. It performed better than TIMI, but what about other decision rules, including physician gestalt. Before declaring HEART the winner they, “would like to see it compared to other rules,” and to physician judgment. In two studies JF covered in 2017 and 2018, that seemed to meet inclusion criteria yet were not included in this analysis, EDACS was arguably better than HEART. I use the HEART score in practice. It helps. But the physician judgment aspect is important - I’m still not likely to discharge a 64 year with troponin 3x normal (HEART = 3).
The EM Ottawa Blog has a comprehensive post of chest pain decision tools.
Evidence Care takes it a step further and incorporates this into point-of-care decision support - for free.
Prognostic Accuracy of the HEART Score for Prediction of Major Adverse Cardiac Events in Patients Presenting with Chest Pain - A Systematic Review and Meta-Analysis. Acad Emerg Med. 2018 Oct 29. doi: 10.1111/acem.13649. [Epub ahead of print]
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