November 2022

JUCM Article Review: The HEAR Score


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Ian L. -

Few General practitioners could tolerate missed acute coronary syndrome whether chest pain per-chest pain new shortness of breath on exertion or new fatigue on exertion.
If it results in a death in any cognitively intact patient with years to live it is catastrophic .
The 2% acceptable mid rate is not explained on the basis that 2% harm by death from over - investigations is a Reality .
With IV tpa for STEMI it is a one percent death rate, so it is hard to believe stress tests or CCTA have a 2% death rate or even PCI and stents .
CABG possibly .

Mike W. -

Good thoughts - this is a tricky situation as we need to balance risk of harm w risk of testing... many CDRs now go for the 1-2% acceptable miss rate. Just to reiterate, the HEAR score is not yet a CDR... thx Ian!

John B. -

One thing that was brought to my attention by an attending was that a low-risk heart score can go home and that people can technically be low risk with an elevated troponin. In the UC for those who are very resistant in not wanted to go to the ER I use the HEART score (But since I don't have a trop in clinic I assume the worst...3x normal limit) if everything else is 0 then the highest their HEART score could be is +2 and still considered low risk. I talk this through with the PT... importance of emergent follow up if anything changes.... how we can't rule out etc...

Mike W. -

This is a good approach. I will say that an elevated troponin would still be a reason to admit, but the scenario you paint is extremely unlikely. A story which is 'slightly suspicious' is still a 0 on the heart score, making an elevated trop also very unlikely. I think your approach for discharge instructions is a VERY good one!

Bonnie S., M.D. -

Having worked for 20 plus years in ED, chest pain can be a difficult diagnosis to exclude cardiac as patient's complaints differ and at time can be very misleading.

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