Cardiology/systematic review/meta-analysis
HEART Score Risk Stratification of Low-Risk Chest Pain Patients in the Emergency Department: A Systematic Review and Meta-Analysis

Presented as an abstract at the Society for Academic Emergency Medicine annual conference, May 2018, Indianapolis, IN.
https://doi.org/10.1016/j.annemergmed.2018.12.010Get rights and content

Study objective

The objectives of this systematic review and meta-analysis are to appraise the evidence in regard to the diagnostic accuracy of a low-risk History, ECG, Age, Risk Factors, and Troponin (HEART) score for prediction of major adverse cardiac events in emergency department (ED) patients. These included 4 subgroup analyses: by geographic region, the use of a modified low-risk HEART score (traditional HEART score [0 to 3] in addition to negative troponin results), using conventional versus high-sensitivity troponin assays in the HEART score, and a comparison of different post–ED-discharge patient follow-up intervals.

Methods

We searched MEDLINE, EBSCO, Web of Science, and Cochrane Database for studies on the diagnostic performance of low-risk HEART scores to predict major adverse cardiac events among ED chest pain patients. Two reviewers independently screened articles for inclusion, assessed the quality of studies with both an adapted Quality Assessment of Diagnostic Accuracy Studies version 2 tool and an internally developed tool that combined components of the Quality in Prognostic Studies; Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies; and Grading of Recommendations Assessment, Development and Evaluation. Pooled sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios were calculated.

Results

There were 25 studies published from 2010 to 2017, with a total of 25,266 patients included in the final meta-analysis, of whom 9,919 (39.3%) were deemed to have low-risk HEART scores (0 to 3). Among patients with low-risk HEART scores, short-term major adverse cardiac events (30 days to 6 weeks) occurred in 2.1% of the population (182/8,832) compared with 21.9% of patients (3,290/15,038) with non–low-risk HEART scores (4 to 10). For patients with HEART scores of 0 to 3, the pooled sensitivity of short-term major adverse cardiac event predictions was 0.96 (95% confidence interval [CI] 0.93 to 0.98), specificity was 0.42 (95% CI 0.36 to 0.49), positive predictive value was 0.19 (95% CI 0.14 to 0.24), negative predictive value was 0.99 (95% CI 0.98 to 0.99), positive likelihood ratio was 1.66 (95% CI 1.50 to 1.85), and negative likelihood ratio was 0.09 (95% CI 0.06 to 0.15). Subgroup analysis showed that lower short-term major adverse cardiac events occurred among North American patients (0.7%), occurred when modified low-risk HEART score was used (0.8%), or occurred when high-sensitivity troponin was used for low-risk HEART score calculations (0.8%).

Conclusion

In this meta-analysis, despite its use in different patient populations, the troponin type used, and timeline of follow-up, a low-risk HEART score had high sensitivity, negative predictive value, and negative likelihood ratio for predicting short-term major adverse cardiac events, although risk of bias and statistical heterogeneity were high.

Introduction

Chest pain accounts for approximately 5% to 10% of US emergency department (ED) visits and is one of the most common complaints among all ED visits worldwide.1, 2 A significant number of chest pain patient visits result in hospitalization to rule out acute coronary syndrome, although few patients require cardiac interventions.3, 4, 5 This clinical practice consequently results in substantial patient overassessment, wasted allocation of already limited health care resources, and increased financial burden for both patients and the overall health care system.

Editor’s Capsule Summary

What is already known on this topic

The History, ECG, Age, Risk Factors, and Troponin (HEART) score has been shown to have high sensitivity in many emergency department–based studies around the world, but surveys of practicing physicians suggest it needs to be even higher (≥98%) to be used clinically.

What question this study addressed

This study confirmed the findings of a previous systematic review and also examined prespecified subgroups for whom the sensitivity of a low-risk HEART score might be higher.

What this study adds to our knowledge

After removal of studies that excluded patients with any positive troponin results, the studies that tested the modified HEART score and those that used only high-sensitivity troponins had the highest sensitivity for predicting short-term major adverse cardiac events (97% and 98%, respectively). Lower 95% confidence intervals were 96% and 91%, respectively.

How this is relevant to clinical practice

For the HEART score to be used clinically, these results suggest that future work should target the modified HEART score, high-sensitivity troponins, or both.

In recent years, multiple chest pain risk-stratification scoring systems (eg, Thrombolysis in Myocardial Infarction, Global Registry of Acute Coronary Events) have been derived and validated in different studies.6, 7, 8 However, most scoring systems are intended to evaluate short-term outcomes, such as mortality or recurrence of myocardial infarction, among hospitalized chest pain patients with history of coronary artery disease. Although their use can be expanded to all chest pain patients, scant evidence exists to support such claims.9, 10 Originally derived in Europe, the History, ECG, Age, Risk Factors, and Troponin (HEART) score is an alternative chest pain risk-stratification tool intended specifically to identify low-risk chest pain patients at the ED and predict potential major adverse cardiac events after ED discharge.11, 12 Chest pain patients with low HEART scores (0 to 3) might be safely discharged from the ED, with very low risk of major adverse cardiac events, in effect potentially minimizing unnecessary hospital admissions and thereby considerably reducing health care costs. To date, one systematic review and meta-analysis has been published on the use of the HEART score in the management of ED chest pain patients with suspected acute coronary syndrome.13

Although the HEART score has been broadly used and validated in clinical studies, it has not been formally included in the American Heart Association guidelines.14, 15 A recent meta-analysis showed that 1.6% of patients with low-risk HEART scores would have had a missed major adverse cardiac event at a mean follow-up time of 6 weeks.13 This pooled major adverse cardiac event occurrence among low-risk chest pain patients still exceeds the acceptable less than 1% miss rate among ED providers willing to discharge these patients directly from the ED.16 Many potential factors could affect the diagnostic and prognostic accuracy of HEART score predictions, including differences in patient populations, provider determination of low-risk HEART score criteria, specific troponin reagent used, and follow-up duration, resulting in high clinical heterogeneity.

We aimed to find an optimal use of the HEART score that may provide improved major adverse cardiac event predictions and a more meaningful guideline for ED providers, thus decreasing the rate of post–ED-discharge major adverse cardiac events in low-risk chest pain patients. We reviewed all relevant studies to assess the diagnostic performance of the low-risk HEART score as a predictor of major adverse cardiac events among ED chest pain patients receiving care in different geographic regions, using different low-risk HEART score criteria, using different troponin reagents, and at distinct post–ED-discharge follow-up intervals.

Section snippets

Study Design and Selection of Participants

A dedicated medical librarian searched MEDLINE (including PubMed and Ovid), EBSCO (Cumulative Index of Nursing and Allied Health, including “choose/select” all databases feature), Web of Science, and the Cochrane Database for publications of the HEART score as a diagnostic factor to predict short-term (within 6 weeks) and long-term (3 months or greater) major adverse cardiac event outcomes. The literature search was filtered to include studies published from 2008 (the year in which the HEART

Characteristics of Study Subjects

Our literature search identified a total of 686 potentially relevant studies. After further independent review of titles and abstracts, 47 studies were considered promising for inclusion. After full-text review and quality assessments, 25 studies met inclusion criteria for this meta-analysis. Details concerning the exclusion process are shown in Figure 1. A summary of all 47 reviewed studies is shown in Table E3, available online at http://www.annemergmed.com.

Main Results

A total of 25 studies were assessed

Limitations

There are several limitations in this study. First, we were not able to include all studies in our meta-analysis, including those published in foreign languages. The exclusion of non-English published studies may have directly affected our subgroup analysis of diverse patient populations across the 3 geographic regions. Second, study eligibility criteria were broad, which may have introduced variations in calculating HEART scores not originally accounted for, and the prevalence of major adverse

Discussion

Chest pain is one of the most common complaints among ED patients. Failure to appropriately investigate a given patient’s chest pain cause presents the risk of sustaining missed acute coronary syndrome, with resulting significantly higher morbidity and mortality.56 This meta-analysis presents consistent results in regard to low-risk HEART scores predictive of short-term major adverse cardiac events, with a pooled sensitivity of 96% and negative likelihood ratio of 0.09. Our study showed that

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  • Cited by (0)

    Please see page 188 for the Editor’s Capsule Summary of this article.

    Supervising editor: Clare L. Atzema, MD, MSc. Specific detailed information about possible conflict of interest for individual editors is available at https://www.annemergmed.com/editors.

    Author contributions: JL-P, KB, and HW were responsible for the design search strategy. JL-P and HW were responsible for the inclusion and exclusion criteria and the development of the initial quality and risk-assessment tool. JL-P and KB were responsible for the electronic and manual search. JL-P, DW, and HW were responsible for the study screening, data extraction, and quality and risk-of-bias assessment. JL-P was responsible for contacting study authors for additional data, and for protocol registration. JL-P, RDR, DW, and HW were responsible for writing the article. All authors were responsible for editing the article. SA, SB, and HW were responsible for data analysis. KB was responsible for conduct of the search strategy. HW takes responsibility for the paper as a whole.

    All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.

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