NEW YORK (Reuters Health)—Use of the HEART score for evaluating patients with chest pain in the emergency department (ED) is not associated with increased major adverse cardiac events, compared with usual care, according to a study in nine Dutch hospitals.
“The routine use of the HEART score during the initial assessment of chest pain patients at the emergency department was just as safe as usual care,” Dr. Judith M. Poldervaart from University Medical Center Utrecht told Reuters Health by email. “It is likely that with increasing acceptance, confidence, and experience with the HEART score, the impact on health care resources and costs will increase.”
The History, Electrocardiogram, Age, Risk factors, and initial Troponin (HEART) score is used to stratify patients with chest pain according to their short-term risk of major adverse cardiac events (MACE). Its effect on daily practice is unknown, so some clinicians remain reluctant to adopt it for regular use.
Dr. Poldervaart and colleagues investigated the safety of using the HEART score in a cluster randomized trial. All nine hospitals started with an initial period of usual care and, at intervals of six weeks, hospitals switched in a randomized order to the use of the HEART score until all hospitals had crossed over. A score of 7 to 10 put patients in a high-risk group for which prompt invasive treatment was advised. Hospitalization for observation and investigation was recommended for the intermediate-risk group (score of 4 to 6). The recommendation for patients with a score of 3 or less was reassurance and discharge without further diagnostic testing, including no second troponin measurement; however, a second troponin test was performed the same or next day while the patient was ambulatory. At their discretion, however, physicians could overrule the score’s recommendation and admit a patient with a low score.
Most patients (47%) received an intermediate HEART score, 39 percent received a low score, and 11 percent received a high score. The six-week cumulative incidence of MACE was 18.9 percent among 1821 patients receiving HEART care and 22.2 percent among 1827 patients receiving usual care, a difference that was within the prespecified noninferiority margin, according to the April 25th Annals of Internal Medicine report.
There were no major differences between HEART care and usual care in the use of healthcare resources, although there was a small decrease in the proportion of patients who underwent exercise stress ECG, nuclear imaging, and coronary angiography during HEART care.
Quality-of-life scores and health outcomes (expressed as quality-adjusted life-years, QALYs) were similar for the two groups, as were the average direct healthcare costs per patient.
“That we did not find a decrease in costs is probably due to the hesitance of physicians to discharge low-risk patients from the ED without further testing,” Dr. Poldervaart explained. “Hopefully, in time (and more publications of the HEART score now appearing almost weekly from all over the world) this effect on use of health care resources will become more apparent.”
The probability that HEART care dominated usual care was 71 percent, and the probability that HEART care was cost-effective and a willingness-to-pay threshold of 20,000 euros (around $22,000) per QALY was 99 percent. Physicians’ nonadherence to HEART guidance occurred in 41 percent of low-risk patients (e.g., admission and additional testing) and 12 percent of high-risk patients (e.g., no further diagnostic testing).
Reasons cited for nonadherence in low-risk patients included intuition (24 percent), an alternative diagnosis being more probable (11 percent), and logistics (9 percent). No reasons were given for the rest.
“The HEART score is a decision support tool, not a strict protocol,” Dr. Poldervaart said. “The HEART score is an accurate tool, but is no gold standard (just as usual care has no 100% sensitivity).”
“Further research should focus on identifying low-risk patients, since the main barriers to follow the rule are in these patients, and at the same time this is the group where considerable reduction in the use of health care resources and harm of overdiagnosis to low-risk patients can be achieved,” she added.
Dr. Udo Hoffmann, chief of cardiovascular imaging at Massachusetts General Hospital in Boston, told Reuters Health by email, “The HEART Score worked in this population, given that no cardiovascular death or MI occurred in this population and the majority of MACE was unstable angina or PCI, which can be medically managed.”
“In my opinion the results strongly support the use of the HEART score as recommended,” he said. “Low-risk HEART score patients can be discharged.”
Dr. Hoffmann added, “It would have been interesting to see whether the physicians’ adherence to recommendations would have increased, if the trial would have incorporated a pilot period, showing participating physicians the results of HEART score care in their own patients. In addition, knowing the motivation for non-adherence in more detail would probably have been very informative.”