Can We Discharge Intermediate Risk HEART Score Patients?

September 6, 2021

Written by Clay Smith

Spoon Feed
Risk of in-hospital clinically relevant adverse cardiac events (CRACE) among patients with a HEART score of 4-6 (with non-diagnostic ECG and negative troponin) was 0.5%. I am not planning to start discharging intermediate risk patients.

Why does this matter?
Most patients admitted for chest pain don’t wind up having ACS. The HEART score is a way to risk stratify patients; those with a low risk score (≤3) may be sent home. Some suggest that those with an intermediate risk score, with nonischemic ECG and negative troponin, could also be discharged. The question is: What is the risk of CRACE for intermediate HEART score (4, 5, & 6) patients admitted to the hospital following an ED work up?

It’s all in the definitions

• Design – This was a retrospective study of 1,118 patients admitted to the hospital for ACS rule-out with a HEART score of 4, 5, or 6, but this “intermediate” HEART score had to include a non-diagnostic ECG and negative troponin.

• Results – CRACE, a composite outcome of, “life-threatening dysrhythmia, inpatient STEMI, cardiac or respiratory arrest, and all-cause mortality during hospitalization,” occurred in 6 patients (0.5%). Six patients had NSTEMI; 15 PCI; 3 CABG. There were 212 provocative tests done and 5 who had a subsequent negative cath.

• Implications – It’s all in the definitions. A patient who threads this needle – that is, has an intermediate HEART score but not because of ECG or troponin criteria – indeed has low risk of CRACE. But if we looked at in-hospital MACE (major adverse coronary events – defined here as a composite of total death, MI, coronary revascularization, stroke, and hospitalization because of heart failure) it would be not 0.5% but 2.4% – that is, 3 deaths; 6 NSTEMI; 15 PCI; 3 CABG; (2.4%; 27 out of 1,118 ). I am not planning to discharge intermediate risk patients just yet.

• Limitations – The authors thought CRACE was a more relevant outcome than the variably defined MACE, but it is more narrow with more severe criteria. The study does not assess longer term 30-day outcomes. This hospital had a mix of patients 81% of whom were Black, which may impact generalizability.

Source
Clinically relevant adverse cardiovascular events in intermediate heart score patients admitted to the hospital following a negative emergency department evaluation. Am J Emerg Med. 2021 Aug;46:469-475. doi: 10.1016/j.ajem.2020.10.065. Epub 2020 Nov 3.