Value of Repeated Troponin Measurements to Improve the Safety of the HEART Score for Chest Pain Patients at the Emergency Department.

OBJECTIVE: The HEART score is a clinical decision support tool for physicians to stratify the risk of major adverse cardiac events (MACE) in patients presenting with chest pain at the emergency department. The score includes 5 elements, including troponin level. Our aim was to compare safety and efficiency of the HEART scores calculated by using the first representative troponin (ie, based on time since symptom onset) compared to the original HEART score, where calculation was based on the first available troponin measurement, irrespective of duration of symptoms. METHODS: We performed a secondary analysis on patients from the HEART-impact trial (2013-2014, the Netherlands). Two HEART scores were calculated for all patients: a HEART score with a T (troponin) element score based on the first available troponin (HEART-first) and 1 with a T element score based on the first representative troponin (ie, at least 3 hours after symptom onset; HEART-representative). We compared all patients' scores and risk categories between HEART-first and HEART-representative. Furthermore, we compared safety (proportion of patients with MACE receiving a low score) and efficiency (proportion of patients with a low score) between HEART-first and HEART-representative. RESULTS: We included 1222 patients. In 882 (72%) patients, the first troponin was representative, resulting in the same HEART-first and HEART-representative score. In the remaining 340 patients the use of HEART-representative led to a different score than HEART-first in 43 patients (3.5%). Out of the 222 patients with MACE, 11 patients (5.0%) received a low score by using HEART-first compared with 10 patients (4.5%) when using HEART-representative (P = 0.83). The number of patients with a low score was similar (P = 0.93) when using the HEART-first (464/1222; 38%) or HEART-representative score (462/1222; 38%). CONCLUSIONS: Using a representative troponin measurement changed the value of the HEART score in only 3.5% of patients and had no impact on safety and efficiency of the HEART score. These results suggest there is no need to wait for a representative troponin measurement and should encourage physicians to adhere to the original HEART score guidelines.

Secondary analysis of frequency, circumstances and consequences of calculation errors of the HEART (history, ECG, age, risk factors and troponin) score at the emergency departments of nine hospitals in the Netherlands.

OBJECTIVE: The HEART score can accurately stratify the risk of major adverse cardiac events (MACE) in patients with chest pain. We investigated the frequency, circumstances and potential consequences of errors in its calculation. METHODS: We performed a secondary analysis of a stepped wedge trial of patients with chest pain presenting to nine Dutch emergency departments. We recalculated HEART scores for all patients by re-evaluating the elements age (A), risk factors (R) and troponin (T) and compared these new scores with those given by physicians in daily practice. We investigated which circumstances increased the probability of incorrect scoring and explored the potential consequences. RESULTS: The HEART score was incorrectly scored in 266 out of 1752 patients (15.2%; 95% CI 13.5% to 16.9%). Most errors occurred in the R ('Risk factors') element (61%). Time of admission, and patient's age or gender did not contribute to errors, but more errors were made in patients with higher scores. In 102 patients (5.8%, 95% CI 4.7% to 6.9%) the incorrect HEART score resulted in incorrect risk categorisation (too low or too high). Patients with an incorrectly calculated HEART score had a higher risk of MACE (OR 1.85; 95% CI 1.37 to 2.50), which was largely related to more errors being made in patients with higher HEART scores. CONCLUSIONS: Our results show that the HEART score was incorrectly calculated in 15% of patients, leading to inappropriate risk categorisation in 5.8% which may have led to suboptimal clinical decision-making and management. Actions should be taken to improve the score's use in daily practice.