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HEAR or HEART Pathway – Can We Drop Troponin?

January 1, 2021

Happy New Year!

Written by Clay Smith

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Patients with a HEAR score of 0 or 1 were at very low risk of MACE within 30 days. We need a larger study to confirm this before putting it into practice.

Why does this matter?
We have covered numerous articles on use of the HEART pathway to risk stratify chest pain patients. What if we dropped the troponin? The HEART pathway consists of history, ECG, age, risk factors, and serial troponins. HEAR would drop the troponin. Could we use HEAR for ACS like we use PERC for PE?

Did you HEAR this?
This was a secondary analysis of a HEART pathway implementation study with 4,979 patients. In patients with very low HEAR score of 0 or 1 (9%; 447/4979), the risk of MACE (composite: death, MI, and PCI) at 30 days was 0.9%. Troponin measurement would have reclassified two patients. One was a cocaine user with chronic troponin elevation who had no change in management. One had clean coronaries and was diagnosed with Takotsubo. Of the two patients who died, both were from existing cancer, not heart disease. Sensitivity was 97.8% (95%CI 94.5% to 99.4%) and NPV 99.1% (95%CI 97.7% to 99.8%). The result of 0.9% falls, “under the 1% benchmark that is generally considered the threshold of acceptability.” However, this study was not designed to measure this outcome, and the 95% confidence interval ranges from 0.2% to 2.3%. We need a larger study to clarify this outcome before we implement the HEAR score in practice.

Identification of very low-risk acute chest pain patients without troponin testing. Emerg Med J. 2020 Nov;37(11):690-695. doi: 10.1136/emermed-2020-209698. Epub 2020 Aug 4.

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What are your thoughts?