Effectiveness of Modified HEART Score in Predicting Major Adverse Cardiac Events.

Objective
The most important problem for emergency physicians in patients presenting with chest pain is deciding whether to discharge the patient or not. Therefore, many scoring systems have been developed to help with this decision making process. We aim to achieve a modified HEART value by combining the VAS value with the HEART score.


Materials and Methods
Data were collected on age, sex, duration of the symptoms, pain severity using a 10-point visual analog scale (VAS), and the presence of a major adverse cardiac event (MACE). The HEART score was calculated and modified (mHEART) by adding 1 point to the total HEART score for a VAS score of ≥7.


Results
During the study period, 4781 patients were admitted, and 293 participants were analyzed. Of the patients, 34(11.6%) experienced MACE within a month after the encounter. The mean VAS scores were 5.65±1.44. However, 77(26.3%) patients had VAS scores ≥7. Taking 3 as the threshold, 42(14.3%) patients had HEART scores of 4 and above, where 47(16.0%) had mHEART scores ≥4. The mHEART scoring demonstrated better test indicators than the HEART score. According to the HEART score, 6(2.3%) of the 251 patients predicted as negative would develop MACE, but this number decreased to 1(0.4%) in 246 using the mHEART score.


Conclusion
Although the HEART score performs reasonably well in discriminating patients who are MACE negative, it is possible to further improve the score by adding the VAS item. After validation by other studies, we would suggest modifying the HEART score by including the VAS item.


Introduction
According to a 2018 report on the global burden of diseases, armed conflicts, cancers, and cardiovascular diseases are becoming increasingly dangerous to worldwide health. In 2017, non-communicable diseases accounted for 73.4% of deaths, of which, 43.4% were because of cardiovascular diseases [1]. The principal ailments related to cardiovascular diseases are angina pectoris (AP) and acute coronary syndrome (ACS), which classically present with chest pain as the main symptom [2]. Therefore, it is crucial to understand the reasons for chest pain in the context of cardiac diseases.
The diagnostic workup of patients with chest pain demands substantial resources, including cardiology and other departments [3]. To decide whether a patient with chest pain will have a major adverse cardiac event (MACE), an urgent response is required. Any delay in the treatment of a MACE will negatively influence the prognosis [4]. Besides, the laboratory workup to detect a MACE requires time and economic reserves. Thus, early and correct recognition of the condition reduces patient anxiety as well as community loads.
Several risk scores, including the GRACE [5], HEART [6], and TIMI scores [7], have been developed to identify a MACE. Although the HEART score is considered the most reliable among the available tools, it fails to identify 2% of the low-risk patients [8], which suggests that there is still room for improvement.
We hypothesize that adding a pain parameter to the HEART score could improve its predictive capacity in estimating major cardiac events and identifying patients with chest pain at low risk for a MACE.
This study aims to investigate the effectiveness of the modified HEART (mHEART) score in predicting MACEs. It also aims at evaluating the usability of the mHEART score in the emergency department.

Study Design
This study was conducted with a cross-sectional design from September 1-15, 2019, with the STROBE guidelines followed in the reporting [9]. All the participants were asked to give individual written informed consent to participate. The study protocol was approved by the local ethics committee of the study hospital (2020/08/73).

Participants
To prevent selection bias, all the patients with chest pain were invited to participate without sampling. None of the included patients had applied before the study period. A total of 3 meetings were conducted with the research team concerning standard data collection and handling. Error checking and debugging were performed after the data were entered into the computer. All the patients (adults >18 years old) with chest pain during the study period were invited to participate in the investigation. A total of 135 patients refused to participate, and patients with ST-elevation myocardial infarction (STEMI) were excluded (n=15). Patients who presented with chest pain and received another diagnosis were similarly excluded from the study as were the patients with any of the following conditions: thoracic wall pathologies (n=3), costochondritis (n=3), fibromyalgia (n=6), pneumonia (n=8), pulmonary embolism (n=3), pneumothorax (n=2), pericarditis (n=1), aortic dissection (n = 2), intestinal pathologies (n=7), and traumatic chest pain (n=14), as well as patients who developed cardiac arrest (n=3) during their evaluation in the emergency room ( Figure 1). • This study will contribute to patient management in the emergency department.

Variables
• It will bring a new approach to patient discharge from the emergency department.
• A new scoring system from our country will come into use. Excluded (STEMI) n=15

Main Points
Accepted to join n=360 Rejected n=135 Chest pain n=495 Other symptoms n=4286 Patients applied n=4781 Other Diagnosis n=52 interpreted as emergency revascularization [10]. Pain assessment was done by self-reporting using a visual analogue scale (VAS) ranging from 0 (no pain at all) to 10 (extremely intense pain). The HEART score was calculated using age, patient history (physician suspicion and previous atherosclerotic disease), ECG findings, and the presence of risk factors (smoking status, presence of diabetes mellitus, family history of cardiovascular disease, hypercholesterolemia, hypertension, and obesity), as described by Six et al. [6]. A HEART score ≤3 is associated with a low risk of developing an endpoint. Thus, it is used as a reference when discharging patients [11].
The primary outcome variable of the study was the mHEART score, which was calculated by adding 1 point to the total HEART score if the patient described a VAS score ≥7.
Each patient was followed for up to 30 days after application to the emergency unit for the presence of a MACE. Follow-ups were made by phone interviews, checking the electronic patient records, and, if necessary, arranging a control visit.

Study Size
The required sample size was calculated for receiver operating characteristics (ROC) analysis, as suggested by Negida et al. [12]. Based on an expected area under the curve (AUC) of 0.860 and an alpha error of 0.05, 286 participants were required to estimate the AUC with a precision of 0.810-0.910 (estimated error=0.05) at a confidence interval of 95%.

Statistical Analysis
The data were analyzed using the

Discussion
The descriptive information in our study was compatible with the literature. This study demonstrated that MACEs are still a critical issue for emergency service physicians. A total of 11% of the discharged, apparently healthy patients with chest pain experienced some MACE within a month. Adding the pain severity experienced by the patient to the HEART score increased its sensitivity from 82.4% to 97.1%, its negative predictive value (NPV) from 97.6% to 99.6%, and its positive predictive value (PPV) from 66.7% to 70.2%, without affecting its specificity of 94.6%.
In this study, the number of male patients was almost double the number of female patients (181 males and 112 females). Sex differences among patients applying to emergency departments because of chest pain are well-known. Men experience more coronary artery-related issues compared with women [13]. In this context, it was even suggested that the clinical guidelines for men and women be modified. In patients with chest pain, the 6-week MACE proportions were 1.6 times lower in women than in men [14]. Thus, early discharge of patients with acute chest pain and a low-risk HEART score might be less safe for men as compared to women. Although we did not check for sex differences in this study, we believe that the issue should be elaborated.
There is continuing search for the best noninvasive test to identify populations at risk for cardiovascular events. Aside from sex, age is considered a primary determinant of cardiovascular risk [10]. Older patients with symptoms of coronary heart disease are at a substantially higher risk of positive non-invasive test results [15]. In our sample, we had an age distribution ranging from 22 to 89 years, and 22.8% of the participants were below 30 years of age. Therefore, we believe that although most cardiac events occur in the elderly, patients with chest pain have a wide range of ages; and therefore, a rigorous evaluation of younger patients is required.
Symptom duration is the principal question that needs to be evaluated in the event of chest pain.
Owing to the disturbing nature of chest pain because of myocardial infarction, patients usually present to a health center within 3 h [16]. In our population, there was a wide variation in the mean duration of the symptoms, ranging from 10 min to 48 h, with a median duration of 1.5 h. As an acute myocardial infarction is more likely if the symptom lasts for 20-59 min, we suggest that this parameter be studied further as a discriminator of MACE.
Troponin is the most established indicator of myocardial ischemia. It is a fundamental part of the emergency workup of patients with chest pain and is included in all major risk stratification instruments [17], and 17 (5.8%) of our patients had elevated troponin levels, all of whom developed MACEs.
Correlations of the severity of chest pain with MACEs were not extensively studied. Scientific reports in this regard are non-conclusive. Although Galinski et al. [18] have mentioned that there is no relationship between pain severity and a diagnosis of acute myocardial infarction, Fukuoka et al. [19] have claimed that severe chest pain may be a signal for interpreting the symptom as cardiac-origin in men. In our study, a cut-off level of 7 in the initial VAS scores provided relatively high values in predicting MACEs.
Chest pain constitutes a significant part of presentations to the emergency department. These patients require utmost attention because of the possibility of severe consequences. However, it is not easy to establish a balance between hospitalizing and discharging patients. If patients are hospitalized, invasive testing, such as coronary angiography, can have drawbacks [20]. The other option is to apply non-invasive stress testing or imaging. Early recognition of a MACE   Sensitivity can reduce the patient burden as well as costs [8]. Several decision support tools, such as the GRACE, HEART, and TIMI scores, were developed to decrease the proportions of MACEs in discharged patients.
At this point, the specificity and NPVs of the tool under question must be reviewed. The NPV of a HEART score ≤3 has been reported as 98% [8]. However, a meta-analysis of 30 studies found the sensitivity and specificity of a HEART score ≥4 in predicting MACE to be 95.5% and 44.6%, respectively. We found comparatively similar values for the HEART score, although they were slightly lower than these reports. Furthermore, an increase in the predictive capacity of the scoring could be achieved by including the VAS criteria. Of the 251 patients, 6 (2.3%) predicted as negative would develop a MACE according to the HEART score; however, this number decreased to 1 (0.4%) in 246 using the mHEART score.
In our article, the HEART score, which consists of objective criteria, has been blended with the VAS value, which is a subjective parameter. It involves the evaluation of subjective criteria and throws light on a different perspective.
In conclusion, this study demonstrates that chest pain is an imperative condition in the emergency department, as it constitutes approximately 10% of all presentations, and major cardiac events require further attention. Approximately 11% of the discharged, apparently healthy patients with chest pain will experience a MACE within a month. Although the HEART score performs fairly well in discriminating MACE-negative patients, it is possible to further improve the score by adding the VAS item. As pain severity is a must-asked variable in all patients with chest pain, this refinement of the HEART score requires no extra time and resources. We, therefore, suggest modifying the HEART score by including the VAS value. The mHEART score can be used in a manner similar to the HEART score; thus, preserving the method of interpretation.
Ethics Committee Approval: Ethics committee approval was received for this study from the ethics committee of Ataturk University Ethics Committee (Decision Number 2020/08/73).