March 22, 2021

The HEAR Score: Does Very Low-Risk Acute Chest Pain Not Require Troponin Testing?

Background:  Chest pain is one of the most frequent presenting patient complaints in emergency departments (ED) and has an extensive differential diagnosis with very different levels of severity (1). Many of these chest pain presentations require a significant stay in the ED to rule out acute coronary syndromes (ACS). Low-risk chest pain has been defined by consensus guidelines as having a less than 1% risk of a Major Adverse Cardiac Event (MACE) - a composite of death, myocardial infarction (MI) and coronary revascularization (2,3). There is certainly an overuse of troponin ordering in certain low-risk chest pain populations, translating into unnecessary resource utilization and possible downstream patient harm. The HEART Pathway combines a History, ECG, Age, Risk factors (HEAR) score and serial troponins to stratify patients with acute chest pain and attempt to identify those who most likely do not have ACS that are most suitable for early discharge from the ED without further testing (4). The HEART Pathway ideally reduces hospitalisations from the ED and outpatient cardiac testing, but it is not known if there exists a sub-population of very low-risk patients who could be objectively identified for discharge without any troponin testing at all. This study sought to measure the MACE rate among very low-risk chest pain patients, as defined by a HEAR score ≤1, and determine whether the HEART Pathway requires troponin testing among very low-risk patients to achieve an accepted missed MACE event rate of less than 1%....Read More