I have just returned to Broome after a month or so eating and drinking my way around Europe. Heading back to work this week and I have been doing quite a bit of listening to the EM:RAP podcasts. Long flights and waiting in airports!
The one podcast that caught my eye (ears) was an episode of ERCast featuring Ammal Mattu (ED ECG guru and super nice guy). It was about the risk stratification of ED chest pain patients. This is a continual bug-bear in most city EDs, and the rural areas struggle even more with less access to specialists, highly-sensitive troponin assays and provocative testing. So when I heard this episode, my rural ED brain went into overdrive.
The scoring system that Dr Mattu was speaking of is the HEART score. Oh great! I hear you all moan – another Cardiology scoring system with a smart acronym… put it with the others eg. TIMI, GRACE… but wait – this one is a bit different. It actually can be used in small EDs, is simple, and now has been externally validated in trials including some centres in Australia. So it ticks all the boxes for my practice.
HEART was derived in the Netherlands by Drs Six and Backus – it has now been externally validated in other countries and settings. The HEART score also differs from previous scores in that it was derived in a general ED population (i.e. the folk we see, whereas TIMI and GRACE were done in CCU patients – ie. folk who already got admitted.
So what is the HEART score? It is in the image below. [ Or you can access an interactive version over at MDCalc here ]
Check out the shape of that curve – it is a beautiful sigma with a nice flat tail on the left! this is a discriminating tool with a good number of “low scoring” punters whom we can send home with confidence.
(1) It did not require a super high-sensitive troponin assay (not available in most rural places).
(2) All of the components of the score can be readily available within minutes – history, ECG, troponin. No serum rhubarb to send away to city labs!
(3) It did require a senior, experienced clinician to take the history, look at the patient and the ECG – this is something we DO have in spades in our EDs!
(4) You can use the HEART score with a single “admission” troponin and the low risk group has a 1.7% risk of badness over 6 weeks….
(5) Now – if you repeat the troponin in say 3 hours you increase the sensitivity (NPV) of the score to > 99%.. which is as good as it gets for these chest pain pathways. [Read Mahler et al in Circ Outcome from March 2015]
(6) And you can do all of this in 3.5 hours i.e. still discharge before the dreaded 4-hour target kicks in and you have to “admit” the low-risk chest pain for another troponin after midnight.
So I am sort of looking forward to my first shift back and secretly hoping to see a patient or two with low-risk sounding chest pain.
This score will not replace commonsense, or that sinking-feeling you get when you see the rotund man sweating bullets on the trolley… but it just might help us sort out the low-risk punters in a practical and EBM happy manner!
Let me hear your thoughts – are you going to use the in your practice?