HEART score to further risk stratify patients with low TIMI scores

From the Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA.
Critical pathways in cardiology 03/2013; 12(1):1-5. DOI: 10.1097/HPC.0b013e31827377e1
Source: PubMed


: The ability to risk stratify patients presenting to the emergency department (ED) with potential acute coronary syndrome (ACS) is critical. The thrombolysis in myocardial infarction (TIMI) risk score can risk stratify ED patients with potential ACS but cannot identify patients safe for ED discharge. The symptom-based HEART score identifies very low-risk patients. Our hypothesis was that patients with a TIMI score of 0 or 1 may be stratified further with the HEART score to identify a group of patients at less than 1% risk of 30-day cardiovascular events.
: We conducted a secondary analysis of a prospective cohort study in a tertiary care hospital ED. Patients with potential ACS who were >30 years of age were included. Data collected included demographics, history, electrocardiogram, laboratories, and components of the TIMI and HEART scores. Follow-up was conducted by structured record review and phone. The main outcome was a composite of death, acute myocardial infarction, or revascularization at 30 days.
: There were 8815 patients enrolled (mean age, 52.8 ± 15.1 years; 57% women, and 69% black). At 30 days, the composite event rate was 8.0% (660 patients): 108 deaths, 410 acute myocardial infarction, and 301 revascularizations. Of the 485 patients with both a TIMI score of 0 and a HEART score of 0, there were no cardiovascular events (95% confidence interval, 0-0.8%); but no other score combination had an upper limit confidence interval less than 1%.
: At all levels of TIMI score, the HEART score was able to further substratify patients with respect to 30-day risk. A HEART score of 0 in a patient with a TIMI of 0 identified a group of patients at less than 1% risk for 30-day adverse events.

26 Reads
  • Source
    • "The ROC analysis further confirmed the effectiveness of ESS in risk prediction. A wide range of variables have been considered for use in cardiac risk stratification tools, for example, patient's cardiac risk factors, HRV parameters, clinical characteristics, biomarkers , and ECG [3]. Although HRV has been used to predict physiological distress for centuries [29], it only received increasing attention in recent decades as a potential predictor of congestive heart failure [30], coronary artery disease [31], post myocardial infarction [32], and acute cardiac complications [15]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Fast and accurate risk stratification is essential in the emergency department (ED) as it allows clinicians to identify chest pain patients who are at high risk of cardiac complications and require intensive monitoring and early intervention. In this paper, we present a novel intelligent scoring system using heart rate variability, 12-lead electrocardiogram (ECG), and vital signs where a hybrid sampling-based ensemble learning strategy is proposed to handle data imbalance. The experiments were conducted on a dataset consisting of 564 chest pain patients recruited at the ED of a tertiary hospital. The proposed ensemble-based scoring system was compared with established scoring methods such as the modified early warning score and the thrombolysis in myocardial infarction score, and showed its effectiveness in predicting acute cardiac complications within 72 h in terms of the receiver operation characteristic analysis.
    IEEE Journal of Biomedical and Health Informatics 11/2014; 18(6):1894-1902. DOI:10.1109/JBHI.2014.2303481 · 1.44 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Study objective: Compare outcomes among emergency department (ED) patients with low-positive (0.01-0.02 ng/mL) vs negative troponin T. Methods: Retrospective cohort study of nonadmitted ED patients with troponin testing at a tertiary-care hospital. Trained research assistants used a structured tool to review charts from all nonadmitted ED patients with troponin testing, 12/1/2009 to 11/30/2010. Outcomes of death and coronary revascularization were assessed at 30 days and 6 months via medical record review, Social Security Death Index searches, and patient contact. Results: There were 57596 ED visits; with 33388 (58%) discharged immediately, 6410 (11%) assigned to the observation unit, and 17798 (31%) admitted or other. Troponin was measured in 2684 (6.7%) of the nonadmitted cases. Troponin was negative in 2523 (94.0%), low positive in 78 (2.9%), and positive (≥0.03 ng/mL) in 83 (3.1%). Of troponin-negative cases, 0.8% (95% CI, 0.4-1.1%) died or were revascularized by 30 days, vs 2.8% (95% CI, 0.0-6.7%) of low-positive cases (risk difference [RD], 2.0%; 95% CI, -1.8 to 5.9%). At 6 months, the rates were 1.7% (95% CI, 1.1-2.2%) and 12.9% (95% CI, 5.0-20.7%) (RD, 11%; 95% CI, 3.3-19.1%). Death alone at 30 days occurred in 0.4% (95% CI, 0.1-0.6%) vs 1.3% (95% CI, 0.0-3.8%) (RD, 0.9%; 95% CI, -1.6 to 3.4%). Death at 6 months occurred in 1.2% (95% CI, 0.8-1.6%) vs 11.7% (95% CI, 4.5-18.9%) (RD, 10%; 95% CI, 3.3-17.7%). Conclusion: Among patients not initially admitted, rates of death and coronary revascularization differed insignificantly at 30 days but significantly at 6 months. Detailed inspection of our results reveals that the bulk of the added risk at 6 months was due to non-cardiac mortality.
    American Journal of Emergency Medicine 05/2014; 32(8). DOI:10.1016/j.ajem.2014.05.013 · 1.27 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Coronary computed tomography angiography (coronary CTA) is a viable alternative to functional imaging in the assessment of patients presenting with acute chest pain (ACP) to the emergency department (ED). The Society of Cardiovascular Computed Tomography Guidelines Committee was formed to develop recommendations for acquiring, interpreting, and reporting of cardiovascular CT to ensure adequate, safe, and efficient use of this modality. Because of the increasing extension of coronary CTA testing for the evaluation of ACP patients, the Committee has been charged with the development of the present document to assist physicians and technologists. These recommendations were produced as an educational tool for practitioners to improve the diagnostic care of patients presenting with acute chest pain to the ED, in the interest of developing systematic standards of practice for coronary CTA based on the best available data or broad expert consensus. Due to the highly variable nature of medical care, and individual and unique patient presentations and circumstances, approaches to patient selection, preparation, protocol selection, interpretation or reporting that differs from these guidelines may represent an appropriate variation based on a legitimate assessment of an individual patient’s needs. The Society of Cardiovascular Computed Tomography Guidelines Committee makes every effort to avoid any actual or potential conflicts of interest that might arise as a result of an outside relationship or a personal interest of a member of the Guidelines Committee or its Writing Groups. Specifically, all members of the Guidelines Committee and of both Writing Committees are asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest relevant to the document topic. The relationships with industry information for Writing Group and Committee members are available in the Acknowledgments section of this document. These are reviewed by the Guidelines Committee and will be updated as changes occur.
    Journal of Cardiovascular Computed Tomography 07/2014; 8(4). DOI:10.1016/j.jcct.2014.06.002 · 2.29 Impact Factor