Is The HEART Score All That?

Is The HEART Score All That?

Stuart Swadron MD and Billy Mallon MD

Take Home Points

1.    The HEART score is a 10 point system which includes history, EKG, age, risk factors and troponin and predicts major cardiac event in 6 weeks.

2.    36.4% of patients were characterized as low risk with a HEART score of 0-3.

3.    Head-to-head comparison of the HEART score with the TIMI and GRACE scores showed superiority.

●      Last year, Cam Berg introduced us to his accelerated diagnostic protocol for low risk chest pain which utilized the TIMI score. The TIMI score has some drawbacks. Now we have the HEART score which targets the patients we see every day.

●      The HEART score is a 10 point system which includes history, EKG, age, risk factors and troponin. It is a predictor of a major cardiac event in 6 weeks.

o      Backus, BE et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013 Oct 3;168(3):2153-8. PMID: 23465250

Modified from: Backus et al.

●      The HEART score offers a chance for emergency medicine to coalesce around a single vehicle that is relatively intuitive and allow us to identify enough low risk patients to send home on a consistent basis. The TIMI score and GRACE scores don’t identify enough patients as low risk. We can’t keep admitting more and more of these low risk patients to our hospitalists and cardiologists. We need a rule that will allow us to send a good sized group of low risk chest pain patients home.

●      Unlike the other decision instruments, the HEART score also identifies a high risk group of patients. If the patient has a HEART score of >6, the possibility of a major adverse cardiac event in the next thirty days is 50.1%. These patients will need a cardiology consult. This decision instrument will carve off a group of patients from the bottom and identify a small group of high risk patients from the top.

o      A TIMI score of 0-1 only identifies about 5% of patients. However, a HEART score of 0-3 identifies 36.4% of patients. The HEART score is much better at allowing an emergency physician to select a reasonably sized group of patients who can go home and receive risk stratification as an outpatient. 

●      Many of the previous decision rules focused on sensitivity at the expense of specificity due to concern about missing an MI.  The HEART score appears to be a better calibration toward greater specificity. So why do the numbers look better? It is not a static playing field. We now have a troponin with high sensitivity that is included in the clinical scoring system. We may be making some progress toward stopping unnecessary work-ups.

●      What does the data say? The Backus study included 2440 patients. The data was gathered prospectively. TIMI and GRACE scores were also obtained on patients and compared head-to-head to the HEART score. They found that the HEART score outperformed the TIMI and GRACE scores.

●      It would be nice to coalesce around one rule to help establish a standard of care. This is an area where the standard of care is thrown at us all of the time. Missed MI and missed ACS are responsible for the highest dollar losses in malpractice cases. If you miss an MI, you will likely lose that case. Maybe this would be less true if we could coalesce around the HEART score. An expert could say, “This person followed our standard of care. The HEART score was 2 or 3 and they sent them home for outpatient workup”.  If we were all using it, it would be defendable as well as being the right thing for patients.