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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. [ABSTRACT FROM AUTHOR]

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]

The SCORE model was calibrated according to mortality statistics for each European country. If it is used for the population aged 40–65, it will predict the possibility of fatal cardiovascular consequences that will appear after 10 years. The aim of this study was to investigate individual risk factors for cardiovascular complications in the adult population in the city of Belgrade. The study was designed as a cross-sectional study. Using Heart Score tool for determining of the total risk of CVD, could be projected to the age of 60, which may be of particular importance for guiding young adults, aged 20 to 30, with low absolute risk but already with an unhealthy risk profile, which will lead to a much higher risk as they age. In our study, predominately were present female participants without hypertension, then male and were dominate frequent non-smokers compared with smokers in male and female. Furthermore, in study population were more present smokers with longer duration of smoking (>10 years). After calculated Heart Score, we can see that 25.6% of respondents have a high risk of cardiovascular event, of which 19.6% high risk, 4.4% very high risk, and 1.6% extremely high risk of developing some an adverse fatal cardiovascular event. The present risk factors and high mortality and morbidity from cardiovascular disease indicate the need for taking preventive measures already in children, with the parallel implementation of population strategies and high risk. [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]

Chest pain (CP), a common presentation in the emergency department (ED) setting, is associated with significant morbidity and mortality if emergency clinicians miss the diagnosis of acute coronary syndrome (ACS). The HEART (History, Electrocardiogram, Age, Risk Factors, Troponin) score had been validated for risk-stratification patients who are at high risk for ACS and major adverse cardiac events (MACE). However, the use of cocaine as a risk factor of the HEART score was controversial. We hypothesized that patients with cocaine-positive (COP) would not be associated with higher risk of 30-day MACE than cocaine-negative (CON) patients. This retrospective study included adult patients who presented to 13 EDs of a University's Medical System between August 7, 2017 to August 19, 2021. Patients who had CP and prospectively calculated HEART scores and urine toxicology tests as part of their clinical evaluation were eligible. Areas Under The Receiver Operating Curve (AUROC) were calculated for the performance of HEART score and 30-day MACE for each group. This study analyzed 46,210 patients' charts, 663 (1.4%) were COP patients. Mean age was statistically similar between groups but there were fewer females in the COP group (26.2% vs 53.2%, p < 0.001). Mean (+/− SD) HEART score was 3.7 (1.4) comparing to 3.1 (1.8, p < 0.001) between COP vs CON groups, respectively. Although more COP patients (54%) had moderate HEART scores (4–6) vs. CON group (35.2%, p < 0.001), rates of 30-day MACE were 1.1% for both groups. HEART score's AUROC was 0.72 for COP and 0.78 for CON groups. AUROC for the Risk Factor among COP patients, which includes cocaine, was poor (0.54). This study, which utilized prospective calculated HEART scores, demonstrated that overall performance of the HEART score was reasonable. Specifically, our analysis showed that the rate of 30-day MACE was not affected by cocaine use as a risk factor. We would recommend clinicians to consider the HEART score for this patient group. [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]

Abstract 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.

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]

Chest pain is a common complaint for consultation of emergency medical services worldwide. Currently, ambulance nurses (AN) base their decision to transport a patient to the hospital on their own professional experience. The HEART score could improve prehospital risk stratification and patient treatment. The aim of this study is to investigate the interrater reliability and predictive accuracy of the HEART score between AN and emergency physicians (EP). A retrospective analysis on data of 569 patients 18 years and older included in two prehospital HEART score studies. The endpoints are interrater reliability (intraclass correlation [ICC]) and predictive accuracy for major adverse cardiac events within 30 days of the HEART score calculated by AN versus EP. Predictive accuracy is sensitivity, specificity, positive predicted value (PPV) and negative predicted value (NPV). Interrater reliability was good for total HEART score (ICC 0.78; 95% CI 0.75-0.81). However, focusing on the decision to transport a patient, the ICC dropped to 0.62 (95% CI 0.62-0.70). History and Risk factors caused the most variability. Predictive accuracy of HEART differed between AN and EP. The HEART score calculated by AN was sensitivity 91%, specificity 38%, PPV 26%, and NPV 95%. The HEART score calculated by EP was sensitivity 98%, specificity 32%, PPV-26%, and NPV 99%. With a cut-off value of 0-2 for a low HEART score, predictive accuracy significantly improved for the HEART score calculated by AN: sensitivity 98%, specificity 18%, PPV 22%, and NPV 98%. Our study shows a moderate interrater reliability and lower predictive accuracy of a HEART score calculated by AN versus EP. AN underestimate the risk of patients with acute chest pain, with the largest discrepancies in the elements History and Risk factors. Reconsidering the cut-off values of the low-risk HEART category, as well as a carefully developed training program, will possibly lead to a higher interrater reliability of the HEART score and higher predictive accuracy used by AN. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Abstract Objectives This study presents a design framework to enhance the accuracy by which large language models (LLMs), like ChatGPT can extract insights from clinical notes. We highlight this framework via prompt refinement for the automated determination of HEART (History, ECG, Age, Risk factors, Troponin risk algorithm) scores in chest pain evaluation. Methods We developed a pipeline for LLM prompt testing, employing stochastic repeat testing and quantifying response errors relative to physician assessment. We evaluated the pipeline for automated HEART score determination across a limited set of 24 synthetic clinical notes representing four simulated patients. To assess whether iterative prompt design could improve the LLMs’ ability to extract complex clinical concepts and apply rule‐based logic to translate them to HEART subscores, we monitored diagnostic performance during prompt iteration. Results Validation included three iterative rounds of prompt improvement for three HEART subscores with 25 repeat trials totaling 1200 queries each for GPT‐3.5 and GPT‐4. For both LLM models, from initial to final prompt design, there was a decrease in the rate of responses with erroneous, non‐numerical subscore answers. Accuracy of numerical responses for HEART subscores (discrete 0–2 point scale) improved for GPT‐4 from the initial to final prompt iteration, decreasing from a mean error of 0.16–0.10 (95% confidence interval: 0.07–0.14) points. Conclusion We established a framework for iterative prompt design in the clinical space. Although the results indicate potential for integrating LLMs in structured clinical note analysis, translation to real, large‐scale clinical data with appropriate data privacy safeguards is needed.

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]

Coronavirus disease 2019 (COVID-19) is known to be associated with cardiovascular complications, but whether the current validated HEART score for chest pain is still applicable for these patients is unknown. This study aims to identify the impact and association of COVID-19 co-infection in patients presenting with chest pain and a calculated HEART score to the emergency departments (ED) with 30-day of major adverse cardiac event (MACE). This is a multicenter, retrospective observational study that included adult (age ≥ 18 years) patients visiting 13 different EDs with chest pain and evaluated using a HEART score. The primary outcome was the percentage of 30-day MACE, which included acute myocardial infarction, emergency percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or death among patients who presented with chest pain and had COVID-19 co-infection. The sensitivity and specificity of the HEART score among COVID-19 co-infection for MACE were assessed by the receiver operating curve (ROC). We analyzed records of 46,210 eligible patients, in which 327 (0.7%) patients were identified as infected with COVID-19. Patients with COVID-19 had higher mean total HEART score of 3.3 (1.7), compared to patients who did not have COVID-19 (3.1, SD 1.8, P = 0.048). The rate of MACE was similar between both groups. There were only 2 (0.6%) COVID-19 patients who had MACE, compared to 504 (1.1%) patients in control group. Total HEART score was associated with an area under the ROC (AUROC) of 0.99, while the control group's was 0.78. History was associated with high AUROC in both COVID-19 (0.74) and control groups (0.76). Older age in COVID-19 had higher AUROC (0.89) than control patients (0.63). Among patients presenting to the ED with chest pain and having COVID-19 infection, HEART score had predictive capability for MACE, similar to patients without COVID-19 infection. Further studies with more COVID-19 patients are still necessary to confirm our observation. [ABSTRACT FROM AUTHOR]

Background: the prognosis of patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) is not benign; thus, prompting the need to validate prognostic scoring systems for this population. Aim: to evaluate and compare the prognostic performance of GRACE, TIMI, HEART, and ACEF scores in MINOCA patients. Methods: A total of 250 MINOCA patients from January 2017 to September 2021 were included. For each patient, the four scores at admission were retrospectively calculated. The primary outcome was a composite of all-cause death and acute myocardial infarction (AMI) at 1-year follow-up. The ability to predict 1-year all-cause death was also tested. Results: Overall, the tested scores presented a sub-optimal performance in predicting the composite major adverse event in MINOCA patients, showing an AUC ranging between 0.7 and 0.8. Among them, the GRACE score appeared to be the best in predicting all-cause death, reaching high specificity with low sensitivity. The best cut-off identified for the GRACE score was 171, higher compared to the cut-off of 140 generally applied to identify high-risk patients with obstructive AMI. When the scores were tested for prediction of 1-year all-cause death, the GRACE and the ACEF score showed very good accuracy (AUC = 0.932 and 0.828, respectively). Conclusion: the prognostic scoring tools, validated in AMI cohorts, could be useful even in MINOCA patients, although their performance appeared sub-optimal, prompting the need for risk assessment tools specific to MINOCA patients. [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]

Feedlot heart disease (FHD) is a condition in fattening beef cattle that arises from right-side heart remodeling resulting from alveolar hypoxia. This hypoxic environment is hypothesized to result from the large body mass of fattened cattle. Sensitive cattle have increased incidence of pulmonary hypertension resulting from compensation mechanisms of the individual. The severity of this remodeling is quantified at harvest by gross examination of the heart utilizing a visual grading system of 1-5, where a score of 1 is a normal heart and a score of 5 is a severely remodeled heart. Previously, heart score was found to contain sire differences and to be moderately heritable. This led to more questions regarding other potential factors influencing heart scores, one of which was breed differences. Therefore, the objective of this study was to examine the prevalence of heart remodeling in beef and dairy cattle breeds and to investigate whether some breeds had a greater prevalence of heart remodeling. Heart scores were collected on Angus-influenced animals raised in the panhandle of Texas (1,103 m) and a Beef x Dairy group raised in western Kansas (846 m). The total number of animal observations was 2,069. Twenty-four percent of the individuals exhibited moderate to severe remodeling (score 3 and greater). Of this cohort, 1,307 animals had breed composition data (i.e., Angus, Simmental, Jersey, and Holstein) suitable for use in the analysis. Breed proportions ranged from 0% to 100% for Angus, 0 to 93.25% for Simmental, 0% to 69.22% for Jersey, and 0% to 78.06% for Holstein. Utilizing a linear regression model with heart score as the response and breed percentages and heart scorers as fixed effects, the importance of breed composition (covariate) was determined. The percentages of Angus influence tended to be associated with heart score (P = 0.0506), with a regression coefficient of -0.005. The percentage of Simmental had an association with the variation in heart score (P < 0.05) and had a regression coefficient of -0.008. Additionally, the percentages of Jersey and Holstein were found to reduce the incidence of heart score by a factor of -0.014 and -0.018 (P < 0.05), respectively. In summary, an increased percentage of either Jersey or Holstein breed resulted in reduced heart scores, while the incidence of beef breeds was found to be associated with some to little difference in the improvement of heart scores, alluding to potential breed advantages in mitigating right sided heart remodeling. [ABSTRACT FROM AUTHOR]

Congestive Heart Failure (CHF) is a cardiopulmonary condition observed in cattle raised in feedlots situated at elevations above 800 m. This condition leads to right-sided heart failure caused by increased pulmonary vessel pressures and cardiopulmonary remodeling, known as pulmonary hypertension (PH). In cattle experiencing PH, pulmonary arterial pressure (PAP) becomes abnormally high, increasing heart muscle load. This load stretches muscle fibers and enlarges the right side of the heart which can lead to heart failure and death. To assess the severity of PH, animals are assigned a heart score (HS) on a scale ranging from 1 to 5 at harvest. A score of 1 represents a normal heart, while a score of 5 indicates extreme heart remodeling. Understanding the relationship between hot carcass weight (HCW), fat depth (FD), and HS in Angus cattle will provide useful information on the impacts of this condition on feedlot performance and profitability. The objective of this study was to determine if a phenotypic relationship between HCW and FD with HS in Angusinfluenced cattle. For this experiment, a total of 798 black, Angus-influenced cattle were used (245 steers, 553 heifers) that were fed near Greeley, CO. The HCW, FD, and HS data from each animal were recorded at harvest. Three general linear models were used to estimate the effects of HS on HCW and FD. Mean HCW and FD were 393.1 kg, (SD = 90.9) and 0.66 mm, (SD = 0.18), respectively, with an average HS of 2.08 (SD = 0.77). For all models, HCW and FD were fit as dependent variables, while lot and HS were included as fixed effects. Model 1 included all HS categories independently. Model 2 divided HS into 2 groups of normal (HS = 1 or 2) or remodeled (HS = 3+). For model 3 HS 3 was removed leaving only HS of 4 or 5 in the remodeled group. For both HCW and FD in Model 1, the overall effect of HS was not significant (P = 0.82 and P = 0.40, respectively). However, when comparing individual scores, animals with a HS = 4 were 15.0 kg lighter for HCW than individuals with a HS = 1 (P < 0.05). Conversely for FD, a non-significant difference (P = 0.74) of -0.33 mm was observed between animals with a HS = 4 versus a HS = 1. Grouping HS into 2 categories in Model 2 did change the outcome, yielding non-significant HCW and FD differences. However, when eliminating the HS = 3 data, a significant reduction in HCW of 16.9 kg (P = 0.05) was observed between the 2 HS groups, whereas non-significant effects on FD remained. These data suggest that at extreme levels of heart remodeling HCW may be extremely impacted negatively [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.

Abstract Study Objective The use of the HEART score to risk stratify patients for short‐term major adverse cardiac events in the emergency department (ED) setting is well established. Although discharge to home for low‐risk HEART score patients is widely accepted as safe practice, there are limited outcomes data on moderate‐risk HEART score patients discharged to home. We investigated the safety of discharging moderate‐risk HEART score patients to home from the ED with established early cardiology follow‐up. Methods We performed a retrospective cohort analysis of patients presenting to the ED with chest pain from April 2020 through December 2020. Patients were evaluated in the ED and underwent serial conventional troponin testing and electrocardiogram (ECG). Clinicians calculated a HEART score and employed shared decision‐making with moderate‐risk patients (score 4–6), offering hospital admission versus discharge home with a formalized process for rapid cardiology follow‐up (within 2 business days). We assessed the frequency of acute myocardial infarction or death at 30 days and before cardiology follow‐up. Results During our study period, 2939 patient encounters were screened for chest pain. Of these, 333 of 547 eligible moderate‐risk HEART score patients were referred for rapid follow‐up. The median time to follow‐up appointment was 2.9 business days (interquartile range 1.3, 6.5), and 264 (79%) of patients kept their follow‐up appointment. One patient (0.3%) suffered death within 30 days, before cardiology follow‐up. There were no myocardial infarctions. Conclusions These results suggest that moderate‐risk HEART score patients may be considered for discharge from the ED with rapid cardiology follow‐up. Formalizing processes to facilitate these early evaluations may represent a viable alternative to hospital admission, without diminishing patient outcomes.

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]

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. 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. 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. 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). 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. • The HEART score is often coupled with serial troponin measurements not part of the original risk stratification tool. • The rate of positive ΔTnI was very low (1.1%) in patient with HEART score 0–3. • No patients with a HEART score 0–3 and a negative initial troponin experienced MACE within 6 weeks. • Serial measurements of conventional troponin provide limited added benefit in ED patients with HEART score 0–3. • Presentation within 3 h of symptoms onset or resolution was associated with greater rates of positive ΔTnI and MACE. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Ravindra Gopaul,1 Robert A Waller,1 Ricci Kalayanamitra,2 Garrett Rucker,3 Andrew Foy4 1Department of Emergency Medicine, Penn State Hershey Medical Center, Hershey, PA, USA; 2Department of Emergency Medicine, Staten Island University Hospital, New York, NY, USA; 3Penn State Milton S. Hershey College of Medicine, Hershey, PA, USA; 4Department of Internal Medicine, Division of Cardiology, Penn State Hershey Medical Center, Hershey, PA, USACorrespondence: Ravindra Gopaul, Email rgopaul@pennstatehealth.psu.eduObjective: The HEART Score is a clinically validated risk stratification tool for patients with chest pain. Using five parameters (History, Electrocardiogram, Age, Risk factors, and Troponin), this instrument categorizes patients as low, moderate, or high risk for major adverse cardiac events within six weeks after evaluation. Of these parameters, History is the most subjective, as providers independently assign their level of clinical suspicion. Overestimation of history, and ultimately the HEART Score, can result in increased resource utilization, expense, and patient risk. We sought to evaluate bias in provider assessment of history when determining the HEART Score.Methods: Emergency medicine (EM) and Cardiology providers received surveys with one of two versions of clinical vignettes randomized at the question level and were asked to estimate the history component of the HEART Score. Vignettes differed by age, risk factors, sex, and socioeconomic status (SES), but both versions should have received the same score for history. Statistical analysis was then used to assess differences in history assessment between vignettes.Results: Of the 884 responses analyzed, most providers overestimated the historical portion of the HEART Score when assessing risk factors, patient distress, age, and lower SES. Many underestimated history with knowledge of a previous negative stress test. When controlling for specialty, the universal theme was overestimation by EM providers and underestimation by cardiologists. Despite the presence of hypertension, gender differences, and the appearance of mild distress, cardiologists were more likely to correctly estimate history compared to EM providers. SES consideration generally led to an underestimation of history by cardiologists. These findings were all statistically significant.Conclusion: Our study demonstrates that both EM and cardiology providers overestimate history when considering prognosticators that are frequently viewed as concerning. Further education on proper usage of the HEART Score is needed for more appropriate scoring of history and improved resource allocation for hospital systems.Keywords: HEART score, physician, provider, history

Objective: To compare the "HEART (History, ECG, Age, Risk factors, Troponin), GRACE (Global Registry of Acute Coronary Events), and TIMI (Thrombolysis in Myocardial Infarction)" scores in predicting major adverse cardiac events (MACE) in patients reporting with undifferentiated cardiac chest pain to the Emergency Department (ED). Study Design: Cross-sectional validation study Duration and place of Study: Emergency Department, Combined Military Hospital, Rawalpindi Pakistan, from Jan to Jun 2021. Methodology: Two hundred and thirty-seven adult patients with atraumatic cardiac-like chest pain and non-diagnostic electrocardiogram (ECG) reporting to the ED were included in the study. HEART, GRACE and TIMI scores were calculated from the data. The number of patients with low risk was identified by each score and compared at a fixed safety level of minimum 95% sensitivity. The potential occurrence of MACE was confirmed using a telephonic follow-up six weeks after the presentation. Results: At an absolute safety level of minimum 95% sensitivity, the HEART score determined 101 patients as "low-risk" with 1.98% MACE missed. The GRACE score identified 49 "low-risk" patients with 4.08% MACE missed, and the TIMI score identified 66 "low-risk" patients with 3.03% MACE missed. Conclusion: Among the three scores under comparison, the HEART score performed better than the GRACE and TIMI scores at the same safety level and surpassed them in differentiating between those with MACE and without MACE. [ABSTRACT FROM AUTHOR]

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. [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]

Objective: It was aimed to compare the serum asprosin levels in patients with ischemic heart disease with healthy subjects, and to evaluate the relationship between asprosin levels with HEART score and mortality in the patients with coronary heart disease. Material and methods: This study was designed as a single-center, prospective study. Sixty-two patients who presented with acute chest pain and underwent digital subtraction coronary angiography and 31 healthy subjects were included in the study. Fasting serum asprosin levels were compared between patients and healthy individuals. The HEART score was calculated for each individual, and its relations with asprosin and one-month mortality were evaluated. Results: The minimum age of 93 cases included in the study was 24, the maximum age was 85, and the median age was 64. HEART score was higher in cases who had mortality within one month (p Conclusion: Serum asprosin level can be used both diagnostically and as a biochemical marker in the evaluation of mortality and prognosis in patients with ischemic heart disease. Key words: acute chest pain, asprosin, HEART score

Introduction. Chest pain (CP) diagnostics accuracy remains debatable for both general practitioners (GP) or emergency department (ED) physicians for patients in HEART score (HS) low- and intermediate-risk groups which prompted us to review our electronic database for all patients admitted via our center’s ED during 2014 to 2020 for CP and suspect acute coronary syndrome. Methods. Patients were divided in function of low- or intermediate-risk HS and assessed during a three month follow up for angiogram results, major adverse cardiac events (MACE), lab results and echo parameters. Results. Of 585 patients included, low-risk HS group (21,4%, 36% were women) had significant coronary disease on angiogram in 68%, while for intermediate-risk HS group (78.6%, with 32.6% women) it was for 18.4% of patients (p < 0,0005). Area under the ROC curve of HS in detecting patients with ischemic heart disease as a cause of CP was 0.771 (95% CI: 0.772–0.820) with best cut-off point HS was calculated at 3.5. Sensitivity and specificity were 89.2% and 57.6% respectively. Adjusting for sex, lab results and HS, AUROC curve of this model was 0.828 (95% CI: 0.786–0.869; p < 0,0005) with cut-off of 77.95. Sensitivity and specificity were 84.9% and 68% respectively. In the three-month follow-up post-discharge, there was a significant difference in MACE between groups (low- vs. intermediate-risk HS was 3.4 vs. 16.7% p < 0.05). Conclusion. HS for our CP patients admitted via our ED by GP and ED physicians’ referral, provides a quick and reliable prediction of ischemic heart disease and MACE.

Objective: To compare the “HEART (History, ECG, Age, Risk factors, Troponin), GRACE (Global Registry of Acute Coronary Events), and TIMI (Thrombolysis in Myocardial Infarction)” scores in predicting major adverse cardiac events (MACE) in patients reporting with undifferentiated cardiac chest pain to the Emergency Department (ED). Study Design: Cross-sectional validation study Duration and place of Study: Emergency Department, Combined Military Hospital, Rawalpindi Pakistan, from Jan to Jun 2021. Methodology: Two hundred and thirty-seven adult patients with atraumatic cardiac-like chest pain and non-diagnostic electrocardiogram (ECG) reporting to the ED were included in the study. HEART, GRACE and TIMI scores were calculated from the data. The number of patients with low risk was identified by each score and compared at a fixed safety level of minimum 95% sensitivity. The potential occurrence of MACE was confirmed using a telephonic follow-up six weeks after the presentation. Results: At an absolute safety level of minimum 95% sensitivity, the HEART score determined 101 patients as “low-risk” with 1.98% MACE missed. The GRACE score identified 49 “low-risk” patients with 4.08% MACE missed, and the TIMI score identified 66 “low-risk” patients with 3.03% MACE missed. Conclusion: Among the three scores under comparison, the HEART score performed better than the GRACE and TIMI scores at the same safety level and surpassed them in differentiating between those with MACE and without MACE.

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. [ABSTRACT FROM AUTHOR]

Background: Patients presenting with chest pain may or may not be experiencing a panic attack. Is chest pain caused by a panic attack or myocardial infarction with non-obstructive coronary arteries (MINOCA) syndrome? Aim: In this study, we evaluated both MINOCA syndrome and HEART score in patients who presented to the emergency department with panic attacks and chest pain. Method: Patients who applied to the emergency department with panic disorder and chest pain complaints were included. Patients who met the MINOCA diagnostic criteria were identified. The study was completed with 143 eligible patients out of a total of 217 patients evaluated. The patients were divided into two groups. The first group was those whose symptoms and test results were consistent with MINOCA. The second group was composed of those whose chest pain was considered non-specific. The HEART score of all patients was calculated. The demographic characteristics, symptoms, and HEART scores were compared between the groups. Results: Of the 143 patients evaluated in the study, 62 (43.3%) were male and 81 (56.7%) were female. While the mean HEART score was 4.7 ± 1.5 in the MINOCA group, it was 2.0 ± 1.0 in the non-cardiac group, a statistically significant difference. Conclusion: Clinicians should pay attention to the patient's age, gender, number of attacks per week, HEART score, and which symptoms (palpitations, shortness of breath, and fear of death) are present in patients who meet the panic attack diagnostic criteria. Clinicians should be alert to the MINOCA syndrome in panic attack patients. [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.

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.

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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]

Introduction. Recent data show that 1/5 of patients with chest pain in emergency room (ER) have an acute coronary syndrome that requires admission and treatment. Current guidelines have endorsed the HEART score for admission, observation or discharge in individual patients. We aimed to assess performance of the HEART score at the University Clinical Centre of the Republic of Srpska. Methods. Between March 1 and March 31, 2019, all patients with chest pain who presented at ER were evaluated. The HEART score for each patient was calculated, and patients were stratified based on the HEART score recommendation, i.e. low-, intermediate- and high-risk. Patients were followed 6 weeks for major adverse cardiac events (MACE). Results. Out of a total of 144 included patients, 23 had low-risk (0−3) HEART scores, while 73 and 48 patients had intermediate-risk (4−6) and high-risk (7−10) HEART scores, respectively. The discordance among intuitive judgments by clinicians and the HEART score advice became typically obtrusive in patients with excessive (7−10) HEART score rankings: 25 out of 48 (52.1%) patients had been discharged, while the remaining 22 patients had been admitted and 1 person was observed. In population with HEART score rankings 4–6, MACE became recognized in 1/73 (1.4%) while in patients with excessive HEART score rankings (values 7–10), MACE befell in 5/48 (10.4%). Only one patient who was discharged experienced MACE. The ROC analysis of the HEART score revealed a value of 0.78, suggesting a good performance in discriminating between low- and high-risk patients. Conclusion. Discordance between clinical decision and HEART score recommendation was not associated with severe clinical consequences.

Abstract Study objectives This study investigated the interrater reliability of the history component of the HEART (history, electrocardiogram, age, risk, troponin) score between physicians in emergency medicine (EM) and internal medicine (IM) at 1 tertiary‐care center. Methods We conducted a retrospective, secondary analysis of 60 encounters selected randomly from a database of 417 patients with chest pain presenting from January to June 2016 to an urban tertiary‐care center. A total of 4 raters (1 EM attending, 1 EM resident, 1 IM attending, and 1 IM resident) scored the previously abstracted history data from these encounters. The primary outcome was the interrater agreement of HEART score history components, as measured by kappa coefficient, between EM and IM attending physicians. Secondary outcomes included the agreement between attending and resident physicians, overall agreement, pairwise percent agreement, and differences in scores assigned. Results The kappa value for the EM attending physician and IM attending physician was 0.33 with 55% agreement. Interrater agreement of the other pairs was substantial between EM attending and resident but was otherwise fair to moderate. Percent agreement between the other pairs ranged from 48.3% to 80%. There was a significant difference in scores assigned and the subgroup in which there was disagreement between the raters demonstrated significantly higher scores by the EM attending and resident when compared to the IM attending. Conclusion This study demonstrates fair agreement between EM and IM attending physicians in the history component of the HEART score with significantly higher scores by the EM attending physician in cases of disagreement at 1 tertiary‐care center.

Background: HEART scores are a well-validated tool used to risk stratify patients with chest pain in the emergency department. Currently, no triage or risk stratification tool is available in the UK prehospital arena. Methods: A comprehensive literature search was carried out to determine the effectiveness of HEART score use by paramedics in the prehospital environment. Findings: Prehospital HEART scores completed by paramedics appear to have a high sensitivity and negative predictive value for detecting major adverse cardiac events. The use of high-sensitivity cardiac troponin assays or a prehospital modified HEART Pathway may allow patients to be triaged based on a single point-of-care (POC) cardiac troponin test. As POC devices improve, this is likely to increase the accuracy of paramedic HEART scores. Additionally, there are some differences between HEART scores calculated by doctors and paramedics. Conclusion: The use of HEART scores prehospitally has the potential to improve patient outcomes. However, issues remain over the accuracy of POC devices and with paramedic interpretation of electrocardiograms and cardiac history-taking. Furthermore, the lack of POC testing in current UK paramedic scopes of practice raises questions over the practicality of introducing HEART scores, which would rely on POC testing. [ABSTRACT FROM AUTHOR]

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. Continuous cardiac monitoring has been recommended for ED patients being evaluated for possible acute coronary syndrome (ACS) due to concern for arrhythmia. Indiscriminate use of monitored beds restricts access for other critically unwell patients and contributes to overcrowding. In this single centre, retrospective study of consecutive ED patients evaluated for possible ACS, a low/intermediate‐risk HEART score identified those at very low risk for having a clinically important arrhythmia while in ED. [ABSTRACT FROM AUTHOR]

Introduction: The HEART scoring system codifies the clinical gestalt used by physicians with 0-2 points assigned to 5 criteria (history, electrocardiography, age, risk factors and troponin). This scoring provides a prognostic tool that assists in disposition planning. The use of a truncated HEART score, minus the troponin data (HEAR score), was used for patients presenting with chest pain at one of four outpost nursing stations served by La Ronge Health Centre in northern Saskatchewan. These nursing stations have no onsite physician and no ability to obtain any troponin data. This study set out to determine if there was any utility in conducting point-of-care (PoC) troponins in these nursing outposts. Materials and Methods: A retrospective analysis was conducted using the La Ronge regional electronic medical record by searching for all patients for whom an outpost nurse had called a physician regarding chest pain symptoms between 01 January 2011 and 31 December 2016. The HEAR and HEART score were then calculated for each individual presentation of patients with chest pain that met inclusion and exclusion criteria. Results: By calculating both the patient's HEART score before evacuation from the outposts and after (i.e. with the troponin data), we were able to determine that, in 89.4% of cases (110/123 events), patients would require evacuation regardless of the troponin values due to a HEART score ≥4. In 10.6% (13/124 events) of cases, the patients who were evacuated had a HEART score ≤3, and in only one case did the troponin data increase this score. Conclusions: The majority of patients would continue to be evacuated regardless of the result of their PoC troponin due to an already elevated HEAR score. PoC troponin is unlikely to reduce the rate of evacuation of patients with chest pain from the nursing stations served by the La Ronge Health Centre. [ABSTRACT FROM AUTHOR]

The HEART score is a widely used clinical decision tool that provides emergency providers with objective risk stratification for patients presenting to the emergency department (ED) with undifferentiated chest pain (CP). There is no data as to which patients undergo formal risk stratification with a HEART score, and whether patient demographics influence decisions to apply the HEART score. Our objective was to determine if sex or race independently predict documentation of patients' HEART scores in CP patients. This is a retrospective cohort study of all patients with a chief complaint of CP who presented to EDs within a single health care system (11 EDs) from September 2018–January 2021. Charts were identified via query of the electronic medical record, and patient age, race, and sex were extracted. The presence or absence of documentation of a HEART score was also recorded. Patient race was categorized as white/non-white. Sex was categorized as male/female. Age was inputted as a continuous variable. We performed logistic regression to determine which variables were associated with documentation of a HEART score. 38,277 patients were included in the study. The median patient age was 51 with IQR 36–64, and 18,927 (47.5%) were male. HEART scores were documented in 24,181. Younger age, female sex, and non-white race were all independent predictors of not having HEART score risk stratification documented in the medical record. Women and non-white patients are less likely to receive HEART score risk stratification when presenting with undifferentiated CP, even when controlling for patient age. Further studies should address whether this influences patient centered outcomes. [ABSTRACT FROM AUTHOR]

Introduction: The HEART score is a widely used clinical decision tool that provides emergency providers with objective risk stratification for patients presenting to the emergency department (ED) with undifferentiated chest pain (CP). There is no data as to which patients undergo formal risk stratification with a HEART score, and whether patient demographics influence decisions to apply the HEART score. Our objective was to determine if sex or race independently predict documentation of patients' HEART scores in CP patients.Methods: This is a retrospective cohort study of all patients with a chief complaint of CP who presented to EDs within a single health care system (11 EDs) from September 2018-January 2021. Charts were identified via query of the electronic medical record, and patient age, race, and sex were extracted. The presence or absence of documentation of a HEART score was also recorded. Patient race was categorized as white/non-white. Sex was categorized as male/female. Age was inputted as a continuous variable. We performed logistic regression to determine which variables were associated with documentation of a HEART score.Results: 38,277 patients were included in the study. The median patient age was 51 with IQR 36-64, and 18,927 (47.5%) were male. HEART scores were documented in 24,181. Younger age, female sex, and non-white race were all independent predictors of not having HEART score risk stratification documented in the medical record.Conclusions: Women and non-white patients are less likely to receive HEART score risk stratification when presenting with undifferentiated CP, even when controlling for patient age. Further studies should address whether this influences patient centered outcomes. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction: HEART score is widely used to stratify patients with chest pain in the emergency department but has never been validated for cocaine-associated chest pain (CACP). We sought to evaluate the performance of HEART score in risk stratifying patients with CACP compared to an age- and sex-matched cohort with non-CACP.Methods: The parent study was an observational cohort study that enrolled consecutive patients with chest pain. We identified patients with CACP and age/sex matched them to patients with non-CACP in 1:2 fashion. HEART score was calculated retrospectively from charts. The primary outcome was major adverse cardiac events (MACE) within 30 days of indexed encounter.Results: We included 156 patients with CACP and 312 age-and sex-matched patients with non-CACP (n = 468, mean age 51 ± 9, 22% females). There was no difference in rate of MACE between the groups (17.9% vs. 15.7%, p = 0.54). Compared to the non-CACP group, the HEART score had lower classification performance in those with CACP (AUC = 0.68 [0.56-0.80] vs. 0.84 [0.78-0.90], p = 0.022). In CACP group, Troponin score had the highest discriminatory value (AUC = 0.72 [0.60-0.85]) and Risk factors score had the lowest (AUC = 0.47 [0.34-0.59]). In patients deemed low-risk by the HEART score, those with CACP were more likely to experience MACE (14% vs. 4%, OR = 3.7 [1.3-10.7], p = 0.016).Conclusion: In patients with CACP, HEART score performs poorly in stratifying risk and is not recommended as a rule out tool to identify those at low risk of MACE. [ABSTRACT FROM AUTHOR]

Clinical estimation of the combined effect of several risk factors is unreliable and this resulted in the development of a number of risk estimation systems to guide clinical practice. Here, after defining general principles of risk estimation, the authors describe the evolution of the European Society of Cardiology's (ESC) Systematic COronary Risk Evaluation (SCORE) risk estimation system and some learnings from the data. They move on to describe the establishment of the ESC's Cardiovascular Risk Collaboration and outline its proposed research directions. First among these is the evolution of SCORE 2, which provides updated, calibrated risk estimates for total cardiovascular events for low, moderate, high, and very high-risk regions of Europe. The authors conclude by considering that the future of risk estimation may be to express risk as years of exposure to a cardiovascular risk factor profile rather than risk over a fixed time period, such as 10 years, and how advances in genetics may permit individualized lifetime risk estimation from childhood on. [ABSTRACT FROM AUTHOR]

Background: Chest pain is a common symptom in urgent primary care. The distinction between urgent and non-urgent causes can be challenging. A modified version of the HEART score, in which troponin is omitted ('simplified HEART') or replaced by the so-called 'sense of alarm' (HEART-GP), may aid in risk stratification. Method: This study involved a retrospective, observational cohort of consecutive patients evaluated for chest pain at a large-scale, out-of-hours, regional primary care facility in the Netherlands, with 6‑week follow-up for major adverse cardiac events (MACEs). The outcome of interest is diagnostic accuracy, including positive predictive value (PPV) and negative predictive value (NPV). Results: We included 664 patients; MACEs occurred in 4.8% (n = 32). For simplified HEART and HEART-GP, we found C‑statistics of 0.86 (95% confidence interval (CI) 0.80–0.91) and 0.90 (95% CI 0.85–0.95), respectively. Optimal diagnostic accuracy was found for a simplified HEART score ≥2 (PPV 9%, NPV 99.7%), HEART-GP score ≥3 (PPV 11%, NPV 99.7%) and HEART-GP score ≥4 (PPV 16%, NPV 99.4%). Physicians referred 157 patients (23.6%) and missed 6 MACEs. A simplified HEART score ≥2 would have picked up 5 cases, at the expense of 332 referrals (50.0%, p < 0.001). A HEART-GP score of ≥3 and ≥4 would have detected 5 and 3 MACEs and led to 293 (44.1%, p < 0.001) and 186 (28.0%, p = 0.18) referrals, respectively. Conclusion: HEART-score modifications including the physicians' 'sense of alarm' may be used as a risk stratification tool for chest pain in primary care in the absence of routine access to troponin assays. Further validation is warranted. [ABSTRACT FROM AUTHOR]