Abstract
Background
To improve early diagnostic and therapeutic decision making, we designed the HEART score for chest pain patients in the emergency department (ED). HEART is an acronym of its components: History, ECG, Age, Risk factors and Troponin. Currently, many chest pain patients undergo exercise testing on the consecutive days after presentation. However, it may be questioned how much diagnostic value the exercise ECG adds when the HEART score is already known.
Methods
A subanalysis was performed of a multicenter prospective validation study of the HEART score, consisting of 248 patients who underwent exercise testing within 7 days after presentation in the ED. Outcome is the predictive value of exercise testing in terms of major adverse cardiac events (MACE) within 6 weeks after presentation.
Results
In low-risk patients (HEART score ≤3), 63.1 % were negative tests, 28.6 % non-conclusive and 8.3 % positive; the latter were all false positives. In the intermediate-risk group (HEART score 4–6), 30.9 % were negative tests, 60.3 % non-conclusive and 8.8 % positive, half of these positives were false positives. In the high-risk patients (HEART score ≥7), 14.3 % were negative tests, 57.1 % non-conclusive and 28.6 % positive, of which half were false positives.
Conclusion
In a chest pain population risk stratified with HEART, exercise testing has only a modest contribution to clinical decision making. 50 % of all tests are non-conclusive, with high rates of false positive tests in all three risk groups. In intermediate-risk patients, negative exercise tests may contribute to the exclusion of disease. Clinicians should rather go for sensitive tests, in particular in patients with low HEART scores.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Ramsay G, Podogrodzka M, McClure C, Fox KAA (2007) Risk prediction in patients presenting with suspected cardiac pain: the GRACE and TMI risk scores versus clinical evaluation. QJM 100:11–18
Goodacre S, Cross E, Arnold J, Angelini K, Capewell S, Nicholl J (2005) The health care burden of acute chest pain. Heart 91:229–230
Kirchberger I, Heier M, Wende R, von Scheidt W, Meisinger C (2012) The patient’s interpretation of myocardial infarction symptoms and its role in the decision process to seek treatment: the MONICA/KORA Myocardial Infarction Registry. Clin Res Cardiol (Epub ahead of print)
Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE 2nd, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B (2007) ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction. J Am Coll Cardiol 50:e1–e157
Bassand JP, Hamm CW, Ardissino D, Boersma E, Budaj A, Avilés FF, Fox KAA, Hasdai D, Ohman EM, Wallentin L, Wijns W (2007) ESC guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. Eur Heart J 28:1598–1660
Post F, Giannitsis E, Riemer T, Maier LS, Schmitt C, Schumacher B, Heusch G, Mudra H, Voigtländer T, Erbel R, Darius H, Katus H, Hamm C, Senges J, Gori T, Münzel T (2012) Pre- and early in-hospital procedures in patients with acute coronary syndromes: first results of the “German chest pain unit registry”. Clin Res Cardiol (Epub ahead of print)
Keller T, Post F, Tzikas S, Schneider A, Arnolds S, Scheiba O, Blankenberg S, Münzel T, Genth-Zotz S (2010) Improved outcome in acute coronary syndrome by establishing a chest pain unit. Clin Res Cardiol 99(3):149–155
Stracke S, Dörr O, Heidt MC, Gündüz D, Neuhof C, Parahuleva M, Tillmanns H, Erdogan A (2010) GRACE risk score as predictor of in-hospital mortality in patients with chest pain. Clin Res Cardiol 99(10):627–631
Six AJ, Backus BE, Kelder JC (2008) Chest pain in the emergency room: value of the HEART score. Neth Heart J 16:191–196
Backus BE, Six AJ, Kelder JC, Mast TP, van den Akker F, Mast G, Monnink HJ, Tooren RM, Doevendans PAFM (2010) Chest pain in the emergency room. A multicenter validation of the HEART score. Crit Pathw Cardiol 9:164–169
Backus BE, Six AJ, Kelder JC, Bosschaert MAR, Mast EG, Mosterd A, Veldkamp RF, Wardeh AJ, Tio R, Braam R, Monnink SHJ, van Tooren R, Mast TP, van den Akker F, Cramer MJM, Poldervaart JM, Hoes AW, Doevendans PA A simple score for the assessment of chest pain patients at the emergency department: a prospective validation study of the HEART score (submitted)
Six AJ, Cullen L, Backus BE, Greenslade J, Parsonage W, Aldous S, Doevendans PA, Than M The HEART score for the assessment of patients with chest pain in the Emergency Department: a multi-national validation study (submitted)
Diamond GA, Forrester JS (1979) Analysis of probability as an aid in the clinical diagnosis of coronary artery disease. N Engl J Med 300:1350–1358
Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregatores G, Kiratzka LF, Jacobs AK, Russell RO, Smith SC (2002) ACC/AHA Guideline update for exercise testing. J Am Coll Cardiol 40:1531–1540
R Development Core Team (2009) R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. ISBN: 3-900051-07-0
Cook NR (2008) Statistical evaluation of prognostic versus diagnostic models: beyond the ROC curve. Clin Chem 54(1):17–23
Gaibazzi N, Reverberi C, Badano L (2011) Usefulness of contrast stress-echocardiography or exercise-electrocardiography to predict long-term acute coronary syndromes in patients presenting with chest pain without electrocardiographic abnormalities or 12-hour troponin elevation. Am J Cardiol 107:161–167
Mahler SA, Hiestand BC, Goff DC, Hoekstra JW, Miller CD (2011) Can the HEART score safely reduce stress testing and cardiac imaging in patients at low risk for major adverse cardiac events? Crit Pathw Cardiol 10:128–133
Gibler WB, Runyon JP, Levy RC, Sayre MR, Kacich R, Hattemer CR, Hamilton C, Gerlach JW, Walsh RA (1995) A rapid diagnostic and treatment center for patients with chest pain in the emergency department. Ann Emerg Med 25:1–8
Blankstein R, Ahmed W, Bamberg F, Rogers IS, Schlett CL, Nasir K, Fontes J, Tawakol A, Brady TJ, Nagurney JT, Hoffmann U, Truong QA (2012) Comparison of exercise treadmill testing with cardiac CT angiography among patients presenting to the emergency room with chest pain: ROMICAT study. Circ Cardiovasc Imaging 5:233–242
Amsterdam EA, Kirk JD, Bluemke DA, Diercks D, Farkouh ME, Garvey JL, Kontos MC, McCord J, Miller TD, Morise A, Newby LK, Ruberg FL, Scordo KA, American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Interdisciplinary Council on Quality of Care and Outcomes Research (2010) Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation 122(17):1756–1776
Author information
Authors and Affiliations
Corresponding author
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Poldervaart, J.M., Six, A.J., Backus, B.E. et al. The predictive value of the exercise ECG for major adverse cardiac events in patients who presented with chest pain in the emergency department. Clin Res Cardiol 102, 305–312 (2013). https://doi.org/10.1007/s00392-012-0535-0
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00392-012-0535-0