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The present study investigated the characteristics of rare but often fatal cases of acute coronary syndrome and aortic dissection and the factors affecting mortality. HEART score, aortic dissection detection risk score, and Global Registry of Acute Coronary Event (GRACE) Score were calculated by evaluating biochemical tests and symptoms/signs of the 20 patients who were admitted to our clinic with a preliminary diagnosis of acute myocardial infarction and subsequently diagnosed with aortic dissection. The assumption of normal distribution was checked with the Shapiro-Wilk test, and independent group comparisons were made with the t test or the Mann-Whitney U test. Relationships between qualitative variables were analyzed with chi-square tests. Relationships between quantitative variables were analyzed with Pearson or Spearman correlation coefficients. Patients with conditions like hypertension and diabetes are at higher risk for aortic dissection. We recommend the use of the GRACE Score with the risk parameters we have determined for the prediction of operative mortality. We suggest that the axillary region and antegrade cerebral perfusion may be preferred as the cannulation area in dissection repair. We emphasize preliminary risk assessment according to the aortic dissection detection risk score and remind physicians that ECG ST-T and troponin changes may be misleading., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Aim: For patients who present to the emergency departments (ED) with undifferentiated chest pain, the risk of major adverse cardiac events (MACE) may be underestimated in low-HEART score patients. We aimed to identify characteristics of patients who were classified as low risk by HEART score but subsequently developed MACE at 6 weeks., Methods: We studied a multiethnic cohort of patients who presented with chest pain arousing suspicion of acute coronary syndrome to EDs in the Netherlands and Singapore. Patients were risk-stratified using HEART score and followed up for MACE at 6 weeks. Risk factors of developing MACE despite low HEART scores (scores 0-3) were identified using logistic and Cox regression models., Results: Among 1376 (39.8%) patients with low HEART scores, 63 (4.6%) developed MACE at 6 weeks. More males (53/806, 6.6%) than females (10/570, 2.8%) with low HEART score developed MACE. There was no difference in outcomes between ethnic groups. Among low-HEART score patients with 2 points for history, 21% developed MACE. Among low-HEART score patients with 1 point for troponin, 50% developed MACE, while 100% of those with 2 points for troponin developed MACE. After adjusting for HEART score and potential confounders, male sex was independently associated with increased odds (OR 4.12, 95%CI 2.14-8.78) and hazards (HR 3.93, 95%CI 1.98-7.79) of developing MACE despite low HEART score., Conclusion: Male sex, highly suspicious history and elevated troponin were disproportionately associated with MACE. These characteristics should prompt clinicians to consider further investigation before discharge., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Females have historically lower rates of cardiovascular testing when compared to males. Clinical decision pathways (CDP) that utilize standardized risk-stratification methods may balance this disparity. We sought to determine whether clinical decision pathways could minimize sex-based differences in the non-invasive workup of chest pain in the emergency department (ED). Moreover, we evaluated whether the HEART score would minimize sex-based differences in risk-stratification., Methods: We conducted a retrospective cohort review of adult ED encounters for chest pain where CDP was employed. Primary outcome was any occurrence of non-invasive imaging (coronary CTA, stress imaging), invasive testing, intervention (PCI or CABG), or death. Secondary outcomes were 30-day major adverse cardiac events (MACE). We stratified HEART scores and primary/secondary outcomes by sex., Results: A total of 1078 charts met criteria for review. Mean age at presentation was 59 years. Females represented 47% of the population. Low, intermediate, and high-risk patients as determined by the HEART score were 17%, 65%, and 18% of the population, respectively, without any significant differences between males and females. Non-invasive testing was similar between males and females when stratified by risk. Males categorized as high risk underwent more coronary angiogram (33% vs. 16%, p = 0.01) and PCI (18% vs. 8%, p = 0.04) than high risk females, but this was not seen in patients categorized as low or intermediate risk. Males experienced more MACE than females (8% vs. 3%, p = 0.001)., Conclusions: We identified no sex-based differences in risk-stratification or non-invasive testing when the CDP was used. High risk males, however, underwent more coronary angiogram and PCI than high risk females, and consequently males experienced more overall MACE than females. This disparity may be explained by sex-based differences in the pathophysiology driving each patient's presentation., (© 2023. The Author(s).)

Background: The HEART score for risk stratifying chest pain patients in the emergency department (ED) has been widely adopted in clinical practice, but is often employed with nonconformant serial troponin measurements., Objective: The primary objective of this study was to examine the utility of obtaining a second conventional 3-h troponin I (TnI) level in ED patients presenting with potential acute coronary syndrome (ACS), stratified by HEART score and duration of symptoms., Methods: This was a retrospective cohort study of consecutive adult ED patients with a complete HEART score. We assessed the utility of repeat TnI measurement by examining the positivity rate of ΔTnI = [Second TnI] - [Initial TnI] stratified by HEART score and time elapsed since onset or resolution of symptoms. Major adverse cardiac events (MACE) within 6 weeks of index visit were assessed., Results: A total of 944 patients were included with 433 (45.9%) assigned a low risk HEART score 0-3. Of the 268 (61.9%) low risk HEART score patients receiving a second TnI, only 3 (1.1%, [0.2-3.2%]) resulted in a positive ΔTnI, one of which occurred in the setting of an elevated initial TnI. Overall, patients presenting within 3 h of symptoms were more likely to experience positive ΔTnI, index MACE and MACE at 6 weeks compared to patients presenting ≥3 h since symptoms onset/resolution and patients with unknown timing of symptoms (15.9% vs 11.0% vs 10.3%, p < 0.001; 10.0% vs 5.3% vs 4.6%, p = 0.021; 12.7% vs 6.6% vs 6.4%, p = 0.047)., Conclusion: Our data suggest serial measurement of conventional troponin provides limited added benefit in low risk HEART score patients, regardless of duration and timing of symptoms. Conversely, serial troponin measurement may confer utility in moderate/high risk HEART score patients, particularly those presenting within 3 h of symptoms., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Aims: Patients with suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) are routinely transferred to the emergency department (ED). A clinical risk score with point-of-care (POC) troponin measurement might enable ambulance paramedics to identify low-risk patients in whom ED evaluation is unnecessary. The aim was to assess safety and healthcare costs of a pre-hospital rule-out strategy using a POC troponin measurement in low-risk suspected NSTE-ACS patients., Methods and Results: This investigator-initiated, randomized clinical trial was conducted in five ambulance regions in the Netherlands. Suspected NSTE-ACS patients with HEAR (History, ECG, Age, Risk factors) score ≤3 were randomized to pre-hospital rule-out with POC troponin measurement or direct transfer to the ED. The sample size calculation was based on the primary outcome of 30-day healthcare costs. Secondary outcome was safety, defined as 30-day major adverse cardiac events (MACE), consisting of ACS, unplanned revascularization or all-cause death. : A total of 863 participants were randomized. Healthcare costs were significantly lower in the pre-hospital strategy (€1349 ± €2051 vs. €1960 ± €1808) with a mean difference of €611 [95% confidence interval (CI): 353-869; P < 0.001]. In the total population, MACE were comparable between groups [3.9% (17/434) in pre-hospital strategy vs. 3.7% (16/429) in ED strategy; P = 0.89]. In the ruled-out ACS population, MACE were very low [0.5% (2/419) vs. 1.0% (4/417)], with a risk difference of -0.5% (95% CI -1.6%-0.7%; P = 0.41) in favour of the pre-hospital strategy., Conclusion: Pre-hospital rule-out of ACS with a POC troponin measurement in low-risk patients significantly reduces healthcare costs while incidence of MACE was low in both strategies., Trial Registration: Clinicaltrials.gov identifier NCT05466591 and International Clinical Trials Registry Platform id NTR 7346., Competing Interests: Conflict of interest C.C. reports a grant from ZonMw (The Netherlands Organisation for Health Research and Development) and consulting fees from AstraZeneca and Xenikos BV; R.R.J.v.K. reports honoraria grants from Bayer and Novartis, P.D. reports grants from Philips, Abbott and AstraZeneca and consulting fees from Philips; N.v.R. reports grants from Abbott, Philips, Medtronic and Biotronik and speaker fees from Microport, Abbott, Rainmed and Bayer. The other authors have no conflicts of interest., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Ischemic heart disease is the leading cause of mortality worldwide, and its prevalence is rising., Objective: The goal of this study was to evaluate the HEART and T-MACS scores for predicting major cardiac events (MACE) in patients presenting to the emergency department with chest pain., Method: This study was single center and prospectively conducted. The demographic information, T-MACS and HEART scores of the participants were recorded and calculated. Acute myocardial infarction (AMI), mortality, and the need for coronary revascularization were considered as major adverse cardiac events (MACEs). The statistical analysis was carried out using SPSS (IBM Statistics, New York) version 24, and significance was determined at the p < 0.05 level., Results: The 514 patients included in our study had a mean age of 52.01 ± 19.10 years, with 55.3% were female and 44.7% was male. A total of 78(%15.1) cases were diagnosed with AMI. Fifty patients (%9.7) underwent percutaneous coronary intervention, 12 (%2.3) patients underwent coronary artery by-pass graft, and 8 (%1.5) patients died within a one-month period. The sensitivity and negative predictive values of the T-MACS score for the very low risk classification were 93.90% (86.3%-98.0%) and 97.7% (94.7%-99.0%), respectively, and the sensitivity and negative predictive values of the HEART score for the low risk classification were 89.59% (77.3%-93.1%) and 96.6% (94.2%-98.0%), respectively. The specificity and positive predictive values for the high risk classification were 99.77% (98.7%-100%) and 97.2% (82.9%-99.6%), respectively for the T-MACS score and 95.14% (92.7%-97%) and 63.2% (51.4%-73.5%), respectively for the HEART score., Conclusion: The T-MACS score was shown to be more accurate than the HEART score in predicting low risk (very low risk for the T-MACS score), high risk, and anticipated one-month risk for MACE in patients coming to the emergency department with chest pain., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: Current guidelines recommend hospital admission for patients who present to the emergency department (ED) with chest pain and are scored as intermediate risk for adverse outcomes based on the HEART score. While hospital admission for these patients allows for timely investigation and treatment, it is a resource-intensive process. This study examines whether intermediate HEART score patients can be safely managed on an outpatient basis through rapid access chest pain clinics., Methods: This retrospective observational study included all ED chest pain patients referred to rapid access clinics from January 2018 to April 2020 in Regina and Saskatoon, Saskatchewan. ED physician HEART scores were used in lieu of reviewer HEART scores when available. The primary outcome was the rate of major adverse coronary events (MACE), a composite measure of death, acute coronary syndrome, stroke, coronary angiography, and revascularization at 6 weeks in intermediate-risk patients. Secondary outcomes were the type of MACE, rate of MACE before rapid access clinic appointment and the most predictive component of the HEART score., Results: There were 1989 ED referrals, of which 817 were for intermediate-risk patients. 9.3% of intermediate-risk patients had a MACE at 6 weeks. MACE occurred before rapid access clinic follow-up in 1.1% of intermediate-risk patients, with coronary angiography being the most common MACE. Excluding coronary angiography, the risk of MACE before rapid access clinic follow-up was 0.7% in intermediate-risk patients. Components of the HEART score most predictive of MACE were troponin (OR 11.0, 95% CI: 3.7-32.3) and history (5.3, 95% CI: 2.4-11.8)., Conclusion: This study demonstrates that rapid access clinics are likely a safe alternative to admission for intermediate-risk chest pain patients and could reduce costly inpatient admissions for chest pain. With angiography excluded, MACE rates were well below the American College of Emergency Physicians cited 2% threshold., (© 2022. The Author(s), under exclusive licence to Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).)

The association between uric acid (UA) and cardio-metabolic conditions has been recognized for a long time. However, recently, a body of evidence has highlighted the independent role of UA in a series of conditions, including renal and cardiovascular diseases. In this light, data regarding the prognostic role of UA in acute coronary syndrome (ACS) is scarce. A total number of 100 patients, 59 males and 41 females, diagnosed with ACS were recruited in this study. At the time of admission to the hospital, the serum level of UA was measured. In addition, the HEART score was calculated based on each patients' profile. Participants were on average 61.37 ± 12.08 years old. The most prevalent risk factors were hypertension (48%), a history of coronary artery disease (40%), and diabetes mellitus (33%). The average serum level of UA was 5.81 ± 1.81 mg/dl, and the calculated HEART score had a median of six (minimum of two and maximum of ten). A positive yet statistically insignificant correlation was found between the measured UA level and the calculated HEART score (R = 0.375, p = 0.090). However, further studies with larger sample size are required to assess the direct association of UA level with major adverse cardiac events in patients with cardiovascular disease., (© 2022 The Authors. Physiological Reports published by Wiley Periodicals LLC on behalf of The Physiological Society and the American Physiological Society.)

Introduction: Early diagnosis of acute coronary syndrome is emergency providers' task. In the last decade, vast amounts of clinical risk stratification scores were developed to decrease the hospital load of patients by selecting them properly. Objective: Together with the diagnostic and therapeutic challenges, decreasing treatment duration is essential for the improvement of acute coronary syndrome prognosis. Our aim was to assess the HEART score's time-and therapy -related effects on acute coronary syndrome detection as a decision support system. Method: We conducted a retrospective, quantitative study at a county state emergency department amongst patients with the myocardial infarction ICD codes. We assessed their admission time, the way they were delivered to the hos-pital, their presenting symptoms, vital parameters, chronic medical conditions, laboratory and imaging results and the time of their admission to the percutan intervention center. We calculated the HEART score retrospectively from the collected data. Results: Our sample size consisted of 360 people. Coronary artery disease (80%) and hypertension (73.3%) were the most common risk factors, while chest pain (80%) and shortness of breath (48.6%) were the most common com-plaints. Coronary artery disease, hypertension and diabetes are not related to percutan coronary intervention admis-sion times (p = 0.110; p = 0.173; p = 0.507). We found a correlation between the presence of chest pain and mortal-ity (p = 0.009). The calculated HEART score had a correlation with the fact of coronary intervention admission (p = 0.005). Conclusion: We conclude that the retrospectively calculated HEART score correlates with percutan coronary inter-vention admission. Choosing the proper risk stratification can increase the lifespan of the patients and hospital cost-efficiency.

Aims: Although pre-hospital risk stratification of patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) by ambulance paramedics is feasible, it has not been investigated in daily practice whether referral decisions based on this risk stratification is safe and does not increase major adverse cardiac events (MACE). In Phase III of the FamouS Triage study, it was investigated whether referral decisions by ambulance paramedics based on a pre-hospital HEART score, is non-inferior to routine management., Methods and Results: FamouS Triage Phase III is a non-inferiority study, comparing the occurrence of MACE before (Phase II) and after (Phase III) implementation of referral decisions based on a pre-hospital HEART score. In Phase II, all patients were risk-stratified and referred to the hospital; in Phase III, low-risk patients (HEART score ≤ 3) were not referred. Primary endpoint was MACE (acute coronary syndrome, revascularization, or death) within 45 days. A total of 1236 patients were included. Mean age was 63 years, 43% were female, 700 patients were included in the second phase and 536 in the third phase in which 149 low-risk patients (28%) were not transferred to the hospital. Occurrence of 45 days MACE was 16.6% in Phase II and 15.7% in Phase III (P = 0.67). Percentage MACE in low-risk patients was 2.9% in Phase II and 1.3% in Phase III. After adjustments for differences in baseline variables, the hazard ratio of 45 days MACE in Phase III was 0.88 (95% confidence interval 0.63-1.25) as compared to Phase II., Conclusion: Pre-hospital risk stratification of patients with suspected NSTE-ACS, avoiding hospitalization of a substantial number of low-risk patients, seems feasible and non-inferior to transferring all patients to the hospital., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Objective: Continuous cardiac monitoring has been recommended for ED patients being evaluated for possible acute coronary syndrome (ACS) due to concern for arrhythmia, although evidence suggests this risk is low. Indiscriminate use of monitored beds restricts access for other critically unwell patients and contributes to overcrowding. The objective of the present study was to determine if a low/intermediate-risk HEART score identified patients at very low risk for a clinically important arrhythmia who could be removed from cardiac monitoring., Methods: This was a single centre, retrospective, cohort study of consecutive ED patients in a tertiary referral hospital evaluated for possible ACS from July to August 2017. Patients with ST-elevation myocardial infarction or an arrhythmia at presentation which would mandate monitoring were excluded. Data was obtained by medical chart review. The primary outcome was the occurrence of an arrhythmia requiring treatment while in ED., Results: Inter-rater reliability for data extraction demonstrated very strong agreement (kappa 0.87, 95% confidence interval 0.83-0.91). There were 653 participants included with 83 (12.7%) having a final diagnosis of ACS. Three (0.5%) clinically important arrhythmias occurred. There were no cases of ventricular tachycardia, ventricular fibrillation or cardiac arrest. Five hundred and forty (82.7%) participants were low/intermediate-risk HEART score and one (0.2%) clinically important arrhythmia occurred (this was supraventricular tachycardia treated by a valsalva manoeuvre)., Conclusion: Among ED patients presenting with a possible ACS, a low/intermediate-risk HEART score identified those at very low risk for having a clinically important arrhythmia while in ED., (© 2021 Australasian College for Emergency Medicine.)

Background: Coronary risk scores (CRS) including History, Electrocardiogram, Age, Risk Factors, Troponin (HEART) score and Emergency Department Assessment of Chest pain Score (EDACS) can help identify patients at low risk of major adverse cardiac events. In the emergency department (ED), there are wide variations in hospital admission rates among patients with chest pain., Objective: This study aimed to evaluate the impact of CRS on the disposition of patients with symptoms suggestive of acute coronary syndrome in the ED., Methods: This retrospective cohort study included 3660 adult patients who presented to the ED with chest pain between January and July in 2019. Study inclusion criteria were age > 18 years and a primary position International Statistical Classification of Diseases and Related Health Problems-10th revision coded diagnosis of angina pectoris (I20.0-I20.9) or chronic ischemic heart disease (I25.0-I25.9) by the treating ED physician. If the treating ED physician completed the electronic structured variables for CRS calculation to assist disposition planning, then the patient would be classified as the CRS group; otherwise, the patient was included in the control group., Results: Among the 2676 patients, 746 were classified into the CRS group, whereas the other 1930 were classified into the control group. There was no significant difference in sex, age, initial vital signs, and ED length of stay between the two groups. The coronary risk factors were similar between the two groups, except for a higher incidence of smokers in the CRS group (19.6% vs. 16.1%, p = 0.031). Compared with the control group, significantly more patients were discharged (70.1% vs. 64.6%) directly from the ED, while fewer patients who were hospitalized (25.9% vs. 29.7%) or against-advise discharge (AAD) (2.6% vs. 4.0%) in the CRS group. Major adverse cardiac events and mortality at 60 days between the two groups were not significantly different., Conclusions: A higher ED discharge rate of the group using CRS may indicate that ED physicians have more confidence in discharging low-risk patients based on CRS., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Current guidelines for patients with suspected acute myocardial infarction are mainly based on troponin testing, commonly requiring an emergency department visit. HEAR score (History, Electrocardiogram, Age, and Risk factors) is a risk stratification tool validated in Europe, deduced from the HEART score (History, Electrocardiogram, Age, Risk factors, and Troponin), already implemented in clinical practice. We aimed to validate the HEAR score to rule out an acute myocardial infarction without needing biomarker testing., Methods: Retrospective cohort study at 15 emergency departments between May 2016 and December 2017. All adult encounters evaluated for possible acute myocardial infarction with a physician-documented HEART score for health plan members of Kaiser Permanente Southern California were included. Patients with an ST-segment elevation myocardial infarction, those under hospice care, or with a "do not resuscitate" status were excluded. HEAR scores from 0-8 were calculated for each encounter and used to report 30-day acute myocardial infarction or all-cause mortality for each score., Results: There were 22,109 patient encounters included in the study. Overall, 30-day acute myocardial infarction or death occurred in 1.1% of patients. Among the 4106 patients (19%) with a HEAR score <2, 3 died and 2 experienced an acute myocardial infarction within 30 days (0.1%; 95% confidence interval, 0.1-0.3). Sensitivity and specificity were 97.9% and 18.8%, respectively., Conclusions: A low HEAR score may accurately identify patients with a very low risk of 30-day acute myocardial infarction or death, representing a cohort of patients who might appropriately forego biomarker testing. Future research is warranted to assess the impact of implementing the HEAR score into routine clinical practice., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Although increasing evidence shows that in patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) both hospital and pre-hospital acquired HEART (History, ECG, Age, Risk factors, Troponin) scores have strong predictive value, pre-hospital and hospital acquired HEART scores have never been compared directly., Methods: In patients with suspected NSTE-ACS, the HEART score was independently prospectively assessed in the pre-hospital setting by ambulance paramedics and in the hospital by physicians. The hospital HEART score was considered the gold standard. Low-risk (HEART score ≤3) was considered a negative test. Endpoint was occurrence of major adverse events within 45 days., Results: A total of 699 patients were included in the analyses. In 516 (74%) patients pre-hospital and hospital risk classification was similar, in 50 (7%) pre-hospital risk classification was false negative (45 days mortality 0%) and in 133 (19%) false positive (45 days mortality 1.5%). False negative risk classifications were caused by differences in history (100%), risk factor assessment (66%) and troponin (18%) and were more common in older patients. Occurrence of major adverse events was comparable in pre-hospital and hospital low-risk patients (2.9% vs. 2.7%, p = 0.9). Incidence of major adverse events was 0% in the true negative group, 26% in the true positive group, 10% in the false negative group and 5% in the false positive group. Predictive value of both pre-hospital and hospital acquired HEART scores was high, although the 'area under the curve' of hospital acquired HEART score was higher (0.84 vs. 0.74, p < 0.001)., Conclusion: In approximately 25% of patients hospital and pre-hospital HEART score risk classifications disagree, mainly by risk overestimation in the pre-hospital group. Since disagreement is primarily caused by different scoring of history and risk factors, additional training may improve pre-hospital scoring., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Purpose: A newly approved, high-sensitivity troponin T (hsTnT) assay may offer opportunities to more rapidly assess for acute coronary syndrome and identify lower thresholds of myocardial injury. As more emergency departments begin to use the hsTnT assay, anticipating barriers to hsTnT implementation success are critical to realizing potential benefits in rapid, accurate patient assessment., Methods: At a tertiary health system emergency department, hsTnT was implemented along with a diagnostic algorithm and a decision tree to aid in utilization. Qualitative interviews with 18 physicians and advance practice providers were conducted 2 months' postimplementation and again 4 to 6 months postimplementation to capture clinician perceptions to hsTnT implementation efforts. Deductive coding was performed using implementation science determinants frameworks to identify emerging themes related to this topic., Results: Four themes emerged from the interviews: 1) the need for additional clinician education, 2) challenges with care handoffs, 3) lack of buy-in from the hospital community, and 4) key successes., Conclusion: Interviews demonstrated that implementation of hsTnT was associated with several implementation barriers from the perspective of emergency department clinicians. Future implementation efforts should focus on diverse and sustained staff educational efforts, models that address challenges with care handoffs between emergency department clinicians and inpatient clinicians, and operational teams that include inpatient clinicians to facilitate buy-in., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: It is not yet investigated whether referral decisions based on prehospital risk stratification of non-ST-elevation Acute Coronary Syndrome (NSTE-ACS) by the complete History, ECG, Age, Risk factors and initial Troponin (HEART) score are feasible and safe. Hypothesis: Implementation of referral decisions based on the prehospital acquired HEART score in patients with suspected NSTE-ACS is feasible and not inferior to routine management in the occurrence of major adverse cardiac events within 45 days. Study design & methods: FamouS Triage 3 is a feasibility study with a before-after sequential design. The aim is to assess whether prehospital HEART-score management including point-of-care troponin measurement is feasible and noninferior to routine management. Primary end point is the occurrence of major adverse cardiac events within 45 days. Conclusion: If referral decisions based on prehospital acquired risk stratification are feasible and noninferior this can become the new prehospital management in suspected NSTE-ACS.

Introduction: This study was conducted to examine the use of the HEART score for risk stratification of chest pain patients presenting to rural Ontario emergency departments (EDs), assessing both its validity in a rural context and its utility in health-care resource management., Methods: This study was a retrospective chart review of adult patients presenting to the ED with chest pain. The HEART score was assessed for its ability to risk-stratify patients (high, moderate and low) in terms of the likelihood of a major adverse cardiac event (MACE) within 6 weeks. The prevalence of follow-up testing for each risk category of patients was then determined such that the potential impact on health resource management was estimated based on the number of tests ordered in low-risk patients., Results: Of the 215 charts included, 24 (11.2%) patients experienced a MACE within 6 weeks. None of the patients with a low HEART score experienced a MACE. In comparison, the incidence of MACE in moderate- and high-risk groups was calculated to be 13.9% (95% confidence interval [CI] [5.91% and 21.89%, respectively]) and 66.7% (95% CI [46.54% and 86.86%, respectively]). Eighteen percent of the low-risk patients received follow-up testing with no positive results suggestive of acute coronary syndrome., Conclusion: Our results provide external validation of the predictive value of the HEART score in determining the risk of MACE in patients presenting to a rural ED with chest pain. Our results also suggest that rates of follow-up testing in low-risk patients may be reduced in communities with limited access to resources., Competing Interests: None

Aims: Coronary computed tomography angiography is increasingly employed in the emergency department for suspected acute coronary syndrome patients. The HEART score has been proposed for initial risk stratification in these patients. The aim of this study was to investigate the diagnostic value and efficiency of the HEART score before coronary computed tomography angiography., Methods and Results: We included patients suspected of acute coronary syndrome who underwent coronary computed tomography angiography in the emergency department. Based on the HEART score, patients were stratified as low-risk (HEART≤3), intermediate-risk (HEART4-6) and high-risk (HEART≥7). We assessed coronary computed tomography angiography for the presence of significant coronary artery disease (>50% stenosis). The primary outcome, the level of major adverse cardiac events, was a composite endpoint of all-cause mortality, acute coronary syndrome or coronary revascularisation within 30 days. The study population consisted of 340 patients (mean age: 55.6±10.1 years, 44.7% women), major adverse cardiac events occurred in 45 (13.2%) patients. The incidence of major adverse cardiac events in patients stratified as low-risk (35.0%), intermediate-risk (56.8%) and high-risk (8.2%) was 3.4%, 12.4% and 60.7%, respectively. All four low-risk patients with major adverse cardiac events had a HEART score of three. An algorithm where coronary computed tomography angiography is reserved for patients with HEART 3-6 resulted in a sensitivity of 97.8%, specificity of 84.1%, negative predictive value of 99.6% and positive predictive value of 48.4%, while reducing the need for coronary computed tomography angiography by 22% ( n =75)., Conclusion: The predictive value of coronary computed tomography angiography for 30-day major adverse cardiac events in suspected acute coronary syndrome patients is good, and reserving coronary computed tomography angiography for HEART score 3-6 patients reduces the number of needed coronary computed tomography angiograms without affecting diagnostic accuracy.

Objective: To demonstrate how decision analytic models (DAMs) can be used to quantify impact of using a (diagnostic or prognostic) prediction model in clinical practice and provide general guidance on how to perform such assessments., Study Design and Setting: A DAM was developed to assess the impact of using the HEART score for predicting major adverse cardiac events (MACE). Impact on patient health outcomes and health care costs was assessed in scenarios by varying compliance with and informed deviation (ID) (using additional clinical knowledge) from HEART score management recommendations. Probabilistic sensitivity analysis was used to assess estimated impact robustness., Results: Impact of using the HEART score on health outcomes and health care costs was influenced by an interplay of compliance with and ID from HEART score management recommendations. Compliance of 50% (with 0% ID) resulted in increased missed MACE and costs compared with usual care. Any compliance combined with at least 50% ID reduced both costs and missed MACE. Other scenarios yielded a reduction in missed MACE at higher costs., Conclusion: Decision analytic modeling is a useful approach to assess impact of using a prediction model in practice on health outcomes and health care costs. This approach is recommended before conducting an impact trial to improve its design and conduct., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Acute coronary syndrome (ACS) is a common, sometimes difficult to diagnose spectrum of diseases occurring after abrupt reduction in blood flow through a coronary artery. Given the diagnostic challenge, it is sensible for emergency physicians to have an approach to prognosticate patients with possible ACS. Multiple prediction models have been developed to help identify patients at increased risk of adverse outcomes. The HEART score is the first model to be derived, validated, and undergo clinical impact studies in emergency department (ED) patients with possible ACS., Objective: To develop a protocol for a prognostic systematic review of the literature evaluating the HEART score as a predictor of major adverse cardiac events (MACE) in patients presenting to the ED with possible ACS., Methods/design: This protocol is reported according to the PRISMA-P statement and is registered on PROSPERO. All methodological tools to be used are endorsed by the Cochrane Prognosis Methods Group. Pre-defined eligibility criteria are provided. Multiple strategies will be used to identify potentially relevant studies. Studies will be selected and data extracted using standardised forms based on the CHARMS checklist. The QUIPS tool will be used to assess the risk of bias within individual studies. Outcome measures will include prevalence, risk ratio, and absolute risk reduction for MACE within 6 weeks of ED evaluation, comparing HEART scores 0-3 versus 4-10. HEART score prognostic performance will be evaluated with the concordance (C) statistic (model discrimination), observed to expected events ratio (model calibration), and a decision curve analysis. Reporting biases and methodological, clinical, and statistical heterogeneity will be scrutinised. Unless deemed inappropriate, a meta-analysis and pre-defined subgroup and sensitivity analyses will be performed. Overall judgements about evidence quality and strength of recommendations will be summarised using the GRADE approach., Discussion: This review will identify, select, and appraise studies evaluating the prognostic performance of the HEART score, producing results of interest to emergency physicians. These results may encourage shared clinical decision-making in the ED by facilitating risk communication with patients and health care providers., Systematic Review Registration: PROSPERO 2017 CRD42017084400 .

Background: The HEART score is a simple and effective tool to predict short-term major adverse cardiovascular events in patients suspected of acute coronary syndrome. Patients are assigned to three risk categories using History, ECG, Age, Risk factors and Troponin (HEART). The purpose is early rule out and discharge is considered safe for patients in the low risk category. Its performance in patients of Asian ethnicity is unknown. We evaluated the performance of the HEART score in patients of Caucasian, Chinese, Indian and Malay ethnicity., Methods: The HEART score was assessed retrospectively in 3456 patients presenting to the emergency department with suspected acute coronary syndrome (1791 Caucasians, 1059 Chinese, 344 Indians, 262 Malays), assigning them into three risk categories., Results: The incidence of major adverse cardiovascular events within six weeks after presentation was similar between the ethnic groups. A smaller proportion of Caucasians was in the low risk category compared with Asians (Caucasians 35.8%, Chinese 43.5%, Indians 45.3%, Malays 44.7%, p<0.001). The negative predictive value of a low HEART score was comparable across the ethnic groups, but lower than previously reported (Caucasians 95.3%, Chinese 95.0%, Indians 96.2%, Malays 96.6%). Also the c-statistic for the HEART score was not significantly different between the groups., Conclusions: These results show that the overall performance of the HEART score is equal among Caucasian and Asian ethnic groups. The event rate in the low risk group, however, was higher than reported in previous studies, which queries the safety of early discharge of patients in the low risk category.

Aims: The objective of this systematic review was to summarise the current evidence on the diagnostic accuracy of the HEART score for predicting major adverse cardiac events in patients presenting with undifferentiated chest pain to the emergency department., Methods and Results: Two investigators independently searched Medline, Embase and Cochrane databases between 2008 and May 2016 identifying eligible studies providing diagnostic accuracy data on the HEART score for predicting major adverse cardiac events as the primary outcome. For the 12 studies meeting inclusion criteria, study characteristics and diagnostic accuracy measures were systematically extracted and study quality assessed using the QUADAS-2 tool. After quality assessment, nine studies including data from 11,217 patients were combined in the meta-analysis applying a generalised linear mixed model approach with random effects assumption (Stata 13.1). In total, 15.4% of patients (range 7.3-29.1%) developed major adverse cardiac events after a mean of 6 weeks' follow-up. Among patients categorised as 'low risk' and suitable for early discharge (HEART score 0-3), the pooled incidence of 'missed' major adverse cardiac events was 1.6%. The pooled sensitivity and specificity of the HEART score for predicting major adverse cardiac events were 96.7% (95% confidence interval (CI) 94.0-98.2%) and 47.0% (95% CI 41.0-53.5%), respectively., Conclusions: Patients with a HEART score of 0-3 are at low risk of incident major adverse cardiac events. As 3.3% of patients with major adverse cardiac events are 'missed' by the HEART score, clinicians must ask whether this risk is acceptably low for clinical implementation.

Background: Accurate identification of patients at risk of major adverse cardiac events (MACE) places a substantial burden on emergency physicians (EPs). Bayesian nomogram for risk stratification in low- to intermediate-risk cardiovascular patients has not been investigated previously., Objective: The objective of this study was to develop a comparative diagnostic model using Bayesian statistics for exercise treadmill test (ETT) and stress echocardiogram (ECHO) to calculate post-test diagnostic risk of MACE using HEART (history, electrocardiogram, age, risk factors, and troponin) risk score as predictor of pretest probability., Methods: Stratification was made by applying HEART scores for the prediction of MACE. Likelihood ratios (LR) were calculated using pooled sensitivity and specificity of ETT and ECHO from the American College of Cardiology Foundation/American Heart Association systematic review. Post-test probabilities were obtained after inserting HEART score and LR into Bayesian nomogram. Analysis of variance was used to assess statistical association., Results: Positive LR (LR+) for ETT was 4.56 and negative LR (LR-) was 0.27; for ECHO, LR+ 5.65 and LR- 0.15. Bayesian statistical modeling post-test probabilities for LR+ and low HEART risk yielded a post-test probability for ETT of 7.75% and 9.09% for ECHO; intermediate risk gave 47.62% and 52.63%, respectively. For LR-, low HEART risk post-test probability for ETT was 0.46% and for ECHO 0.26%; intermediate risk probabilities were 4.48% and 2.49%, respectively. LR- was statistically significant in ruling out MACE with ECHO (p < 0.001), but no significant differences were seen for LR+ (p = 0.64)., Conclusions: This Bayesian analysis demonstrated slight superiority of stress ECHO over ETT in low- and intermediate-risk patients in ruling out MACE., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Coronary risk scores, such as History, Electrocardiogram, Age, Risk Factors, and Troponin (HEART) and Emergency Department Assessment of Chest Pain Score (EDACS) scores, help nurses identify suspected acute coronary syndrome (ACS) patients who have a risk for major adverse cardiac events (MACE) within 30 days. Aim: To compare the accuracy of HEART and EDACS scores in predicting major events among patients suspected of ACS in the cardiac emergency department (ED). Design and methods: A prospective correlational observational study design was performed on cardiac ED patients who presented with suspected ACS. Tools: Three tools were utilized to collect data pertinent to the study: Tool I comprises patients’ assessment (personal characteristics, risk factors for ACS, and chest pain assessment sheet); Tool II is the risk assessment tool that includes HEART and EDACS scores; and Tool III is MACE incidence among studied patients within 30 days. Results: HEART score was significantly (P < .01) higher among patients for whom MACE was present than absent. However, EDACS score showed no significant difference (P > .05) among patients whose MACE was present or absent. HEART risk score >6 correctly predicted MACE cases with sensitivity and specificity of 77.46% and 48.28%, respectively. However, EDACS score >18 correctly predicted MACE cases with sensitivity and specificity of 42.25% and 75.86%, respectively. Conclusion: This study concludes that HEART score has better sensitivity than EDACS in predicting MACE among suspected ACS patients at the cardiac ED. The HEART score provides the nurses with a quicker and more reliable predictor of MACE shortly after the arrival of the suspected ACS patients at the cardiac ED than the EDACS score. The study recommended the implementation of a HEART score in the cardiac ED for predicting MACE in suspected ACS patients. Follow up closely for high-risk patients to MACE. An educational program should be made for nurses about the implementation of the heart score in the cardiac ED. [ABSTRACT FROM AUTHOR]

Chest pain is among the most common reasons for presentation to the emergency department (ED) worldwide. Additional studies on most cost-effective ways of differentiating serious vs. benign causes of chest pain are needed. Our study aimed to evaluate the effectiveness of a novel risk stratification pathway utilizing 5th generation high-sensitivity cardiac troponin T assay (Hs-cTnT) and HEART score (History, Electrocardiogram, Age, Risk factors, Troponin) in assessing nontraumatic chest pain patients in reducing ED resource utilization. A retrospective chart review was performed 6 months prior to and after the implementation of a novel risk stratification pathway that combined hs-cTnT with HEART score to guide evaluation of adult patients presenting with nontraumatic chest pain at a large academic quaternary care ED. Primary outcome was ED length of stay (LOS); secondary outcomes included cardiology consult rates, admission rates, number of ED boarders, and number of eloped patients. A total of 1707 patients and 1529 patients were included pre- and postimplementation, respectively. Median overall ED LOS decreased from 317 to 286 min, an absolute reduction of 31 min (95% confidence interval 22–41 min), after pathway implementation (p < 0.001). Furthermore, cardiology consult rate decreased from 26.9% to 16.0% (p < 0.0001), rate of admission decreased from 30.1% to 22.7% (p < 0.0001), and number of ED boarders as a proportion of all nontraumatic chest pain patients decreased from 25.13% preimplementation to 18.63% postimplementation (p < 0.0001). Implementation of our novel chest pain pathway improved numerous ED throughput metrics in the evaluation of nontraumatic chest pain patients. [ABSTRACT FROM AUTHOR]

We aimed to compare the predictive ability of the newly introduced Symptoms, history of Vascular disease, Electrocardiography, Age, and Troponin (SVEAT) score with the widely used History, ECG, Age, Risk factors, and Troponin I (HEART) score in risk stratification for 30-day major adverse cardiac events (MACE) development among patients presenting to the emergency department with acute chest pain complaints. This prospective, observational, single-center study was conducted at an emergency department of a tertiary care hospital between June 2022 and January 2023. We recruited all adult patients aged 24 years and above with a primary complaint of non- traumatic chest pain at the critical care unit of the Emergency Department. Inclusion Criteria: Patients aged 24 years and above with a primary complaint of chest pain lasting >5 min. Exclusion Criteria: Patients with STEMI, pregnant individuals, those with traumatic chest pain, and those without 30-day MACE data were excluded. HEART and SVEAT scores were calculated for each participant.The performance of the SVEAT score in identifying the low-risk patient group was compared to that of the HEART score. In the study, out of 809 patients, 589 (72.8%) were categorized as low-risk based on the SVEAT score, and 377 (46.6%) based on the HEART score. Out of these 809 patients, 115 (14.2%) experienced MACE. Within the group classified as low risk by the SVEAT score, 6 (0.7%) patients experienced MACE, while within the group classified as low risk by the HEART score, 8 (1%) patients experienced MACE. The SVEAT score had an Area Under the Curve (AUC) of 0.916 (95% CI 0.890 to 0.942), which was found to be higher than the AUC of the HEART score (0.856, 95% CI 0.822 to 0.890). In our study, the sensitivity of the SVEAT and HEART scores was found to be 94.7% (95% CI 88.9%–98.0%) and 93.0% (95% CI 86.7%–96.9%), respectively. The specificity of both scores was 84.1% (95% CI 81.0%–86.6%) and 53.17% (95% CI 49.3%–56.6%), respectively. While our study indicated a higher predictive power for MACE development with the SVEAT score compared to the HEART score, further extensive studies are necessary for its reliable implementation in emergency departments for chest pain risk classification. [ABSTRACT FROM AUTHOR]

Background: Peripheral artery disease is a condition that causes narrowing of the arteries, impairing circulation to the extremities. Globally, it affects millions of people and is more prevalent in older adults and those with diabetes, high blood pressure, or high cholesterol. There is an overlap specific to polyvascular patients, and almost 50% of patients with PAD have coronary artery disease. Compelling evidence reveals a noteworthy association between PAD and major adverse cardiovascular events (MACEs) in individuals experiencing acute coronary syndrome (ACS) but limited knowledge exists regarding the influence of PAD on left ventricular systolic function during ACS. Methods: In a retrospective case–control study, we examined 100 participants who presented with ACS (mean age = 61.03 years, 80 [80%] males). The patients were divided into two groups: the ACS-PAD group (32 subjects, 74% of them with STEMI, 10% with NSTEMI, and 16% with NSTEACS) and the ACS-nonPAD group (68 participants). Results: This study highlighted that PAD negatively impacts patients with non-ST-segment elevation myocardial infarction (NSTEMI). These patients were likely to experience a decline of approximately 19.3% in their left ventricular ejection fraction (LVEF) compared to the ACS-nonPAD group (p = 0.003) and presented a worse clinical status (the PAD group correlated with Killip class IV, p = 0.049). Conclusion: Our analysis indicates that patients diagnosed with NSTEACS and PAD tend to have a higher LVEF of over 55% and a lower HEART score. Patients with PAD tend to have a functionally higher EF but clinically present with more unstable scenarios (pulmonary edema and cardiogenic shock). This is mainly driven by a higher prevalence of HFpEF in the PAD group. Looking closer at the PAD group, they have a higher incidence of comorbidities such as diabetes, hypertension, high cholesterol, CAD, and stroke, as well as being more active smokers. [ABSTRACT FROM AUTHOR]

Background: Chest pain is the most common symptom in patients who get admitted to the emergency department. Those patients must be assessed for having or developing Acute Coronary Syndrome (ACS). Early diagnosis of ACS is associated with a good prognosis of the patient if they receive targeted treatment. But, about 80 % of patients have no characteristic presentation to conclude the diagnosis of ACS. This leads to time delay due to the duration of clinical observation and unnecessary treatment. Materials and Methods: This hospital based observational study was done between Jan 2020 and September 2021 at a tertiary care institute of South India. About 101 patients who presented to the emergency department of the institute with chest pain have been enrolled into the study. Patients who presented to the emergency OPD with the symptom of chest pain and were above the age of 40 years of any gender were included in the study. Results: Around 39 percent of the study participants have significant ST elevation on ECG. 56 percent of the study participants have one or two risk factors and only 4 percent have more than or equal to 3 risk factors according to the HEART score. 26 percent of study participants have low risk; 47 percent have moderate risk and 27 percent have a high risk for getting Acute Coronary Syndrome according to the Heart Score. Conclusion: Thus, HEART score is an efficient and time-consuming tool that can be used in the emergency Out-patient department to stratify the patients for management. [ABSTRACT FROM AUTHOR]

BACKGROUND: Patients with suspected acute coronary syndrome (ACS) in whom myocardial infarction has been ruled out are still at risk of having obstructive coronary artery disease (CAD). This rate is higher among patients with intermediate high-sensitivity troponin I (hsTnI) concentrations (5 ng/L to 99th percentile) than low concentrations (<5 ng/L). Therefore, an intermediate concentration has been suggested as a candidate for downstream investigation with computed tomography coronary angiography (CTCA). We tried to compare the HEART score-guided vs. hsTnI-guided approach for identifying obstructive CAD. METHODS: From a prospective cohort study of patients presenting to the emergency department with suspected ACS, 433 patients without elevated hsTnI who also underwent CTCA were selected and analyzed. The performances of hsTnI concentration and HEART score were compared using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS: Overall, 120 (27.7%) patients had obstructive CAD. Patients with intermediate hsTnI concentrations were more likely to have obstructive CAD than those with low hsTnI concentrations (40.0% vs. 18.1%); patients with non-low-risk HEART scores (≥4 points) were also more likely to have obstructive CAD than those with low-risk scores (0 to 3 points) (41.0% vs. 7.6%). The HEART score had higher sensitivity and NPV for detecting obstructive CAD in each classification than hsTnI concentration (sensitivity: 89.2% vs. 63.3%; NPV: 92.4% vs. 81.9%, respectively). CONCLUSION: After excluding myocardial infarction in patients with suspected ACS, adding the HEART score for selecting candidates for CTCA could improve patient risk stratification more accurately than relying on hsTnI concentration. [ABSTRACT FROM AUTHOR]

Background: Chest pain represents a prevalent complaint in emergency departments (EDs), where the precise differentiation between acute coronary syndrome and alternative conditions assumes paramount significance. This pilot study aimed to assess the HEART score's implementation in West Balkan EDs. Methods: A retrospective analysis was performed on a prospective cohort comprising patients presenting with chest pain admitted to EDs in Sarajevo, Zenica, and Belgrade between July and December 2022. Results: A total of 303 patients were included, with 128 classified as low-risk based on the HEART score and 175 classified as moderate-to-high-risk. The low-risk patients exhibited younger age and a lower prevalence of cardiovascular risk factors. Laboratory and anamnestic findings revealed higher levels of C-reactive protein, ALT, and creatinine, higher rates of moderately to highly suspicious chest pain history, a greater number of cardiovascular risk factors, and elevated troponin levels in moderate-to-high-risk patients. Comparatively, among patients with a low HEART score, 2.3% experienced MACE, whereas those with a moderate-to high-risk HEART score had a MACE rate of 10.2%. A moderate-to-high-risk HEART score demonstrated a sensitivity of 91.2% (95%CI 90.2–93.4%) and specificity of 46.5% (95%CI 39.9–48.3%) for predicting MACE. Conclusion: This pilot study offers preliminary insights into the integration of the HEART score within the emergency departments of the West Balkan region. [ABSTRACT FROM AUTHOR]

ObjectiveWe sought to identify sub-groups of "low-risk" HEART score patients (history, ECG, age, risk factors, and troponin) at elevated risk of acute myocardial infarction or death within 30 days.MethodsWe performed a secondary analysis of prospective emergency department (ED) encounters for suspected acute coronary syndrome in a large health system with low-risk HEART scores (0-5 points). Logistic regression using the 5 components of the HEART score analyzed the increase risk attributable to points from each of the 5 score components.ResultsOf 30,971 encounters among 28,992 unique patients, 135 (0.44%, 95% confidence interval [CI] = 0.37-0.51) experienced acute myocardial infarction or death. Risk increased for each component of the HEART score from 0 to 1 to 2 points (history, 0.4% to 0.5% to 0.6%; ECG, 0.3% to 0.7% to 0.7%; age, 0.2% to 0.3% to 0.7%; risk factors, 0.1% to 0.4% to 0.8%), except troponin, which had the highest risk with 1 point (troponin, 0.4% to 2.7% to 0.9%). Odds ratios from our regression, which adjusts for other components, showed a similar pattern (from 1 vs 0 and 2 vs 0 points, respectively: history, 1.0 and 1.8; ECG, 2.2 and 3.5; age, 1.2 and 2.1; risk factors, 2.4 and 4.2; and troponin, 6.0 and 3.6).ConclusionAmong "low-risk" suspected acute coronary syndrome encounters, increasing points within each of the 5 categories demonstrated small increases in risk of death or acute myocardial infarction, with the troponin and ECG components representing the largest risk increases.

Introduction: Acute coronary syndrome is very challenging & sometimes very confusing to diagnose. The HEART score was designed to be a prognostic prediction model, using information from the patient's history, ECG, age, risk factors, and troponin level at the initial emergency department. This study was conducted to assess the role of HEART score in predicting major adverse cardiac events in patients with possible acute coronary syndrome presenting to the emergency department. Methods: This prospective observational study was conducted among 453 patients presented with acute coronary syndrome (ACS) at the Department of Cardiology, National Institute of Cardiovascular Diseases, Dhaka, Bangladesh from January 2023 to June 2023 to assess the role of HEART score in predicting major adverse cardiac events (MACE) in patients with possible acute coronary syndrome. The study population was divided into two groups depending on HEART score. MACE was observed between these two groups. Results: Mean age of the respondents was 53.45±11.23 years where 77.7% of them were male. 55% had smoking habit, 36% had history of Diabetes Mellitus, and 38% had history of HTN. Among the respondents 62.9 % was improved. 11.03 % respondents developed heart failure, 14.34% recurrent ischemic pain, 7.9% of recurrent MI, 2.8 % cardiogenic shock, and 0.88 % cases of death. HEART score as predictor was statistically significant (X²=69.7, df=1, p<0.05), indicated to distinguish between major adverse cardiac events and no major cardiac events. Conclusion: Almost one third of respondents with high HEART score had heart failure and recurrent ischemic pain. There was statistically significant difference in incidence of major adverse cardiac events between high and low HEART score groups. The HEART score can be used to predict risk for major adverse cardiac events effectively in patients with suspected ACS. This can help us to determine needs for urgent treatment and hospitalization among the patients who present with suspected ACS. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to determine the risk assessment of acute coronary syndrome and prediction of major adverse cardiac events by HEART (History, ECG, Age, Risk factors, Troponin) and HEARTS3 (HEART + 3S = Sex, Serial 2-h ECG, and Serial 2-h delta Troponin) scoring systems in patients admitted to the emergency department with chest pain. Methods: This is a single-center prospective cohort study. This study was conducted in patients admitted to the emergency department with chest pain, without ST-elevation myocardial infarction, who were 18 years or older, and agreed to participate in the study. The primary endpoint is the occurrence of major adverse cardiovascular events within 30 days. The receiver operating characteristic curve was used to assess the power of HEART and HEARTS3 scores to predict major adverse cardiovascular events. Results: The mean age of 239 patients was 47.91 ± 13.93 years and 72.4% (173) were male. Major adverse cardiovascular events developed in 20.1% (48) of the patients. The mean HEART and HEARTS3 scores of the patients with major adverse cardiovascular events (5.67 ± 1.46 and 9.38 ± 3.91, respectively) were both statistically and significantly higher than the scores of the patients without major adverse cardiovascular events (2.33 ± 1.44 and 2.22 ± 1.39; p = 0.001). The area under the curve values of HEART and HEARTS3 scores were found to be 0.943 (95% confidence interval: 0.905–0.968) and 0.990 (0.968–0.999), respectively. Conclusion: In our study, the power of HEARTS3 score to predict major adverse cardiovascular events was better in the risk assessment of acute coronary syndrome in patients admitted to the emergency department with chest pain compared to the HEART score. We think that patients with a low HEARTS3 score can be safely discharged from emergency department without further cardiac examination. [ABSTRACT FROM AUTHOR]

Abstract The association between uric acid (UA) and cardio‐metabolic conditions has been recognized for a long time. However, recently, a body of evidence has highlighted the independent role of UA in a series of conditions, including renal and cardiovascular diseases. In this light, data regarding the prognostic role of UA in acute coronary syndrome (ACS) is scarce. A total number of 100 patients, 59 males and 41 females, diagnosed with ACS were recruited in this study. At the time of admission to the hospital, the serum level of UA was measured. In addition, the HEART score was calculated based on each patients' profile. Participants were on average 61.37 ± 12.08 years old. The most prevalent risk factors were hypertension (48%), a history of coronary artery disease (40%), and diabetes mellitus (33%). The average serum level of UA was 5.81 ± 1.81 mg/dl, and the calculated HEART score had a median of six (minimum of two and maximum of ten). A positive yet statistically insignificant correlation was found between the measured UA level and the calculated HEART score (R = 0.375, p = 0.090). However, further studies with larger sample size are required to assess the direct association of UA level with major adverse cardiac events in patients with cardiovascular disease.

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Background: The HEART score is reported to be a useful tool for the assessment of suspected acute coronary syndrome (ACS) patients, however, data regarding its validity in our population is scarce. Therefore, aim of this study was to evaluate the prognostic utility of the HEART score to predict major adverse cardiac events (MACE) within 6 weeks in patients presenting to emergency department with chest pain. Methods: This prospective observational study included suspected ACS patients presented with chest pain to the emergency department of a tertiary care cardiac center. Inclusion criteria for the study were consecutive adult patients with suspected ACS, patients with definite diagnosis of ACS based on history, electrocardiography (ECG), and cardiac enzymes were excluded from the study. HEART score was calculated and patients with ≥7 score were also excluded. MACE over the 6-weeks after discharge were observed. Results: Total of 281 patients were included in this analysis, 191 (68%) were male and mean age was 52.58±10.63 years. Mean HEART score was calculated to be 4.27±1.06 with 70.8% (199) in moderate risk [4-6]. Area under the curve of HEART score for the prediction of 6-weeks MACE was 0.874 [0.827-0.920] with MACE rate of 31.7% vs. 0% for low- and moderate-risk group respectively. Conclusion: HEART score showed good discriminating power for the prediction of 6-weeks MACE. Risk of MACE for the patients with HEART score of 0-3 is very low and such patients can be discharged from ER without extensive cardiac workup with proper follow-up planned. [ABSTRACT FROM AUTHOR]

Objective To rapidly and safely identify the risk of developing acute coronary syndrome in patients with chest pain who present to the emergency department, the clinical use of the History, Electrocardiogram, Age, Risk Factors, and Troponin (HEART) scoring has recently been proposed. This study aimed to assess the inter-rater reliability of the HEART score calculated by a large number of Italian emergency physicians. Methods The study was conducted in three academic emergency departments using clinical scenarios obtained from medical records of patients with chest pain. Twenty physicians, who took the HEART score course, independently assigned a score to different clinical scenarios, which were randomly administered to the participants, and data were collected and recorded in a spreadsheet by an independent investigator who was blinded to the study’s aim. Results After applying the exclusion criteria, 53 scenarios were finally included in the analysis. The general inter-rater reliability was good (kappa statistics [κ], 0.63; 95% confidence interval, 0.57 to 0.70), and a good inter-rater agreement for the high- and low-risk classes (HEART score, 7 to 10 and 0 to 3, respectively; κ, 0.60 to 0.73) was observed, whereas a moderate agreement was found for the intermediate-risk class (HEART score, 4 to 6; κ, 0.51). Among the different items of the HEART score, history and electrocardiogram had the worse agreement (κ, 0.37 and 0.42, respectively). Conclusion The HEART score had good inter-rater reliability, particularly among the high- and low-risk classes. The modest agreement for history suggests that major improvements are needed for objectively assessing this component.

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. [ABSTRACT FROM AUTHOR]

Abstract Background Acute coronary syndrome (ACS) is a common, sometimes difficult to diagnose spectrum of diseases occurring after abrupt reduction in blood flow through a coronary artery. Given the diagnostic challenge, it is sensible for emergency physicians to have an approach to prognosticate patients with possible ACS. Multiple prediction models have been developed to help identify patients at increased risk of adverse outcomes. The HEART score is the first model to be derived, validated, and undergo clinical impact studies in emergency department (ED) patients with possible ACS. Objective To develop a protocol for a prognostic systematic review of the literature evaluating the HEART score as a predictor of major adverse cardiac events (MACE) in patients presenting to the ED with possible ACS. Methods/design This protocol is reported according to the PRISMA-P statement and is registered on PROSPERO. All methodological tools to be used are endorsed by the Cochrane Prognosis Methods Group. Pre-defined eligibility criteria are provided. Multiple strategies will be used to identify potentially relevant studies. Studies will be selected and data extracted using standardised forms based on the CHARMS checklist. The QUIPS tool will be used to assess the risk of bias within individual studies. Outcome measures will include prevalence, risk ratio, and absolute risk reduction for MACE within 6 weeks of ED evaluation, comparing HEART scores 0–3 versus 4–10. HEART score prognostic performance will be evaluated with the concordance (C) statistic (model discrimination), observed to expected events ratio (model calibration), and a decision curve analysis. Reporting biases and methodological, clinical, and statistical heterogeneity will be scrutinised. Unless deemed inappropriate, a meta-analysis and pre-defined subgroup and sensitivity analyses will be performed. Overall judgements about evidence quality and strength of recommendations will be summarised using the GRADE approach. Discussion This review will identify, select, and appraise studies evaluating the prognostic performance of the HEART score, producing results of interest to emergency physicians. These results may encourage shared clinical decision-making in the ED by facilitating risk communication with patients and health care providers. Systematic review registration PROSPERO 2017 CRD42017084400.

In the majority of patients with chest pain, an acute coronary syndrome (ACS) can be ruled out. However, early recognition of an ACS is required in order to start treatment as soon as possible and reduce risks associated with myocardial ischaemia. Because of the lack of pre-hospital protocols to rule out an ACS, patients with a suspected ACS are transported to the emergency department, where the HEART score can be used to estimate the risk of major adverse cardiac events (MACE). Patients with a low HEART score have a low risk of MACE. A point-of-care (POC) troponin measurement enables ambulance paramedics to calculate the HEART score in the pre-hospital setting. POC troponin measurement and HEART score assessment have several potential advantages, including early recognition of an ACS and identification of high-risk patients before hospital arrival. Moreover, pre-hospital rule-out of an ACS could prevent unnecessary emergency department visits. The safety and cost-effectiveness of referring low-risk patients with a normal POC troponin value to the general practitioner are currently being investigated in the ARTICA randomised trial. This point-of-view article demonstrates one of the potential advantages of early detection of an ACS. [ABSTRACT FROM AUTHOR]

Background: This study compared the performance of a single blood draw of high-sensitivity troponin T (hsTnT), high-sensitivity troponin I (hsTnI) and conventional troponin I (cTnI) within a modified HEART score for predicting 30-day MACE at Emergency Department (ED) presentation, and established local reference norms for all three assays by determining the cut-off point which yielded the highest sensitivity and negative predictive value for acute myocardial infarction and 30-day MACE.Methods: This single-center prospective cohort study recruited chest pain patients at the ED, whose hsTnT, hsTnI and cTnI were taken on admission. Subjects were classified into low and non-low risk group according to their modified HEART score, with MACE as the primary endpoint. Receiver-operating characteristic (ROC) curves were generated, area under the curves (AUCs) were calculated; the performance characteristics were determined.Results: The performance of modified HEART scores was comparable among the three assays for 30-day MACE (84.9-87.0% sensitivity, 95.6-96.0% NPV, 95%CI) and none of these had very high AUC and specificity (AUC 0.70-0.71, 53.7-56.7% specificity, 95% CI). The modified HEART score using a single blood draw of either hsTnT (3.9ng/L), hsTnI (0.9ng/L) or cTnI (0.0ng/L) at presentation yielded a sensitivity of 100% for 30-day MACE.Conclusion: The modified HEART score using a single blood draw of either hsTnT, hsTnI or cTnI was equally effective in risk-stratifying chest pain patients for safe discharge. The theoretical cut-off points yielding 100% sensitivity are potentially useful (when achieved) for safely discharging low risk patients with undifferentiated chest pain in the ED. [ABSTRACT FROM AUTHOR]

Objectives: To explore the predictive value of HEART and GRACE risk score for major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS). Methods: Retrospective analysis was made on 591 ACS patients who were admitted to our hospital from June 2015 to June 2018. The risk stratification (low risk group, medium risk group and high risk group) of the study subjects was carried out by using HEART and GRACE risk score respectively. The occurrence of MACE was followed up 90 d after the onset of ACS, and the relationship between the occurrence of MACE and the score 90 d after the onset of ACS patients with different risk stratification was analyzed and the predictive ability of the two scoring systems for 90 d MACE events in ACS patients was compared. Results: 371 patients were enrolled in this study, including 324 males (87.3%), 47 females (12.7%) and 167 patients (45.1 %) who developed MACE within 3 months. With the higher risk scores of HEART and GRACE, the incidence of 90 d MACE events increased significantly (P<0.05), The accuracy of predicting MACE in high-risk group of HEART score was higher than GRACE score, while the accuracy of predicting MACE in low-risk group of GRACE score was higher than HEART score. The sensitivity of HEART and GRACE scores for predicting MACE in ACS patients was 76.51%, 64.73%, and specificity was 96.71% and 96.25%. HEART score has a good predictive value. The area under ROC curve is 0.908 (95% CI 0.846-0.974), compared with 0.801 under ROC curve of GRACE score, there is a significant difference (P<0.05). Conclusions: Both HEART and GRACE scores can be applied to risk stratification, prognosis assessment and prediction of MACE in ACS patients, but HEART risk score is more reliable. [ABSTRACT FROM AUTHOR]

Background and purpose: Chest pain (CP) is one of the most frequent chief complaints of patients presenting to the emergency department (ED). Diagnoses range from life-threatening acute coronary syndrome (ACS) to less concerning musculoskeletal injury. Patients are frequently admitted for comprehensive cardiac evaluation. However, it is estimated that <10% are diagnosed with ACS. Identifying low-risk patients who can be safely discharged from the ED results in lower cost burden and less patient days. The HEART Score is a recently validated tool for undifferentiated CP in the ED used to identify low-risk patients. The purpose of this project was to ascertain if the HEART Score could be utilized in the Veteran population for the evaluation of undifferentiated chest pain. Local problem: There is no standard assessment tool used in the ED at the Veterans Administration Pittsburgh Healthcare System (VAPHS) to evaluate CP in low-risk patents. Methods: As part of a quality improvement initiative, a retrospective analysis was performed on patients presenting to the ED with CP over a 6-month period. A total of 197 VAPHS patients were identified through the computerized medical record system. HEART Scores were calculated for each patient. Patients scored as low risk (score of 0-3) were further evaluated for major adverse cardiac events (MACE) and cost saving. Conclusions: Approximately 28% (56) of the patients presenting to the ED with CP were at low risk based on the HEART Score. There were no MACE. There were cost savings compared with usual care ($1,145 vs. $4,700). Implications for practice: The HEART Score can be safely used to identify low-risk patients and result in cost savings for Veteran population. Background/local problem [ABSTRACT FROM AUTHOR]

Emergency physicians must be able to effectively prognosticate outcomes for patients presenting to the Emergency Department (ED) with chest pain. The HEART score offers a prognostication tool, but external validation studies are limited. We conducted an external retrospective validation study of the HEART score among ED patients presenting to our ED with chest pain from 1 January 2014 to 9 June 2014. We utilized chart review methodology to abstract data from each patient's electronic medical record. We collected data relevant to each of the five elements of the HEART score: history, electrocardiogram (ECG) interpretation, patient age, patient risk factors, and troponin levels. We calculated the diagnostic accuracy of the HEART score (0-10) for predicting the primary outcome of major adverse cardiac events (MACE) over 6 weeks following the ED visit (coronary revascularization, myocardial infarction, or mortality). We randomly selected 10% of patient charts from which a second investigator abstracted all data to assess inter-rater reliability for all study variables. Of 625 charts reviewed, we abstracted data on 417 (66.7%) consecutive patients meeting study inclusion criteria. Thirty-one (7.4%) of these patients experienced 6-week MACE. We observed no instances of MACE within 6 weeks among subjects with a HEART score of 3 or less. The area under the receiver operator curve (AUROC) is 0.885 (95% confidence interval 0.838-0.931). Patients with a HEART score ≤3 are at low risk for 6-week MACE. Hence, these patients may be candidates for outpatient follow-up instead of inpatient admission for cardiac risk stratification. [ABSTRACT FROM AUTHOR]

Chest pain is one of the most common, potentially serious presenting complaints for adult emergency department (ED) visits. The challenge of acute coronary syndrome (ACS) identification with appropriate disposition is quite significant. Many of these patients are low risk and can be managed non-urgently in the outpatient environment; other patients, however, are intermediate to high risk for ACS and should be managed more aggressively, likely with inpatient admission and cardiology consultation. The HEART score, a recently derived clinical decision rule aimed at the identification of risk in the undifferentiated chest pain patient, is potentially quite useful as an adjunct to physician medical decision-making. The HEART score identifies patients at low, intermediate, and high risk for short-term adverse outcome resulting from ACS. As is true of all such clinical decision rules, the physician should consider the information provided the HEART score yet exercise clinical judgment in the ultimate determination of management strategy in the adult chest pain patient suspected of ACS. [ABSTRACT FROM AUTHOR]

The HEART score is a simple scoring system, ranging from 0 to 10, specifically developed for risk stratification of patients with undifferentiated chest pain. It has been validated for the conventional troponin, but not for high-sensitive troponin. We assess a modified version of the HEART score using a single high-sensitivity troponin T dosage at presentation, regardless of symptom duration, and with different ECG criteria to evaluate if the patients with a low HEART score could be safely discharged early. The secondary aim was to confirm a statistically significant difference in each HEART score group (low 0-3, intermediate 4-6, high 7-10) in the occurrence of major adverse cardiac events at 30 and 180 days. We retrospectively analyzed the HEART score of 1597 consecutive patients admitted to the Emergency Department of our Hospital for chest pain between January 1 and June 30, 2014. Of these, 190 did not meet the inclusion criteria and 29 were lost to follow-up. None of the 512 (37.2 %) patients with a low HEART score had an event within 180 days. The difference between the cumulative incidences of events in the three HEART score groups was statistically significant (P < 0.0001). We demonstrate that it might be possible to safely discharge Emergency Department chest pain patients with a low modified HEART score after an initial determination of high-sensitive troponin T, without a prolonged observation period or an additional cardiac testing. [ABSTRACT FROM AUTHOR]

Background The performance of the GRACE, HEART and TIMI scores were compared in predicting the probability of major adverse cardiac events (MACE) in chest pain patients presenting at the emergency department (ED), in particular their ability to identify patients at low risk. Methods Chest pain patients presenting at the ED in nine Dutch hospitals were included. The primary outcome was MACE within 6 weeks. The HEART score was determined by the treating physician at the ED. The GRACE and TIMI score were calculated based on prospectively collected data. Performance of the scores was compared by calculating AUC curves. Additionally, the number of low-risk patients identified by each score were compared at a fixed level of safety of at least 95% or 98% sensitivity. Results In total, 1748 patients were included. The AUC of GRACE, HEART, and TIMI were 0.73 (95% CI: 0.70–0.76%), 0.86 (95% CI: 0.84–0.88%) and 0.80 (95% CI: 0.78–0.83%), respectively (all differences in AUC highly statistically significant). At an absolute level of safety of at least 98% sensitivity, the GRACE score identified 231 patients as “low risk” in which 2.2% a MACE was missed; the HEART score identified 381 patients as “low risk” with 0.8% missed MACE. The TIMI score identified no “low risk” patients at this safety level. Conclusions The HEART score outperformed the GRACE and TIMI scores in discriminating between those with and without MACE in chest pain patients, and identified the largest group of low-risk patients at the same level of safety. [ABSTRACT FROM AUTHOR]