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
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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.
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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.
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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.
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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.
In Canada we would never admit someone with intermediate risk and negative troponins. Almost all our chest pain patients go home and have outpatient stress tests unless they are very high risk.