Chest pain is the number-two reason people go to the emergency department (stomach pain is number one). While the vast majority of patients are not having a heart attack, the process for ruling out a heart attack can involve extensive testing and a hospital stay. But there’s a better approach now gaining traction in the US—one that was developed more than a decade ago in the Netherlands…
THE “HEART” OF THE MATTER
For some patients, symptoms along with results from blood tests and an electrocardiogram (EKG) provide indisputable proof that a heart attack has occurred or is occurring. But, for many others, these first tests are inconclusive. It’s then up to the ER doctor to make a judgment call about next steps to further investigate what’s then termed “low-risk chest pain.”
In the US, most patients with low-risk chest pain wind up being admitted to the hospital for observation and further testing, such as a cardiac stress test, to be certain that a heart attack wasn’t missed. Yet the “miss rate,” or amount of heart attacks that were missed, is just 2.1% of these patients. That means that nearly all of them are having unnecessary and expensive procedures.
As hospitals try to use evidence-based guidelines to improve cost and quality of care, some emergency departments are starting to use the Dutch-developed 10-point scoring system called HEART, an evidence-based, decision-making tool designed to reduce miss rates and unnecessary admissions. HEART is an acronym for the five markers that are evaluated—history, EKG, age, risk factors and troponin.
This is how the scoring works…
History: Patients are given 2 points if they have high-risk symptoms such as heavy chest pain, sweating, nausea and vomiting, relief after taking nitroglycerin or pain that gets worse with exertion…1 point if the chest pain is sharp rather than heavy and is not accompanied by other symptoms…and 0 if symptoms are mostly low-risk for heart attack.
EKG: Patients are given 2 points if they have signs of decreased blood flow and other changes…1 point if there are EKG changes that are not specifically indicative of heart disease…and 0 if normal.
Age: Patients are given 2 points if 65 or older…1 point if between 45 to 64…and 0 if under 45.
Risk factors: Patients are given 2 points if they have a history of coronary heart disease, peripheral artery disease, stroke or three or more heart attack risk factors such as obesity, diabetes, high blood pressure, high cholesterol or a family history of heart disease…1 point for one or two of these risk factors…and 0 for no risk factors.
Troponin: Troponin, a protein involved in muscle contraction, is measured with a blood test. It can signal heart muscle damage. Patients are given 2 points for a high troponin level…1 point if it is borderline…and 0 if it is within the normal range.
A score that totals 0 to 3 means there’s low risk for heart attack, and patients are likely to be sent home and told to follow up with their primary care provider.
A score of 4 to 6 signals moderate risk, and patients will be admitted for observation and possible cardiac stress testing.
A score of 7 to 10 is high risk, and these patients are admitted to the hospital and referred to a cardiologist for treatment.
THE US GETS HEART SMART
While there have been a few other scoring systems available to doctors, international studies have consistently shown that HEART outperforms them all.
Kaiser Permanente Southern California, a large health-care organization, decided to adopt HEART at 14 of its area hospitals and review the results. An analysis of all 12,000 patients given HEART scoring found that, rather than the expected 2.1% miss rate, it was just 0.18%. (A “miss” is defined as any patient sent home without a diagnosis of heart attack and who went on to have a heart event in the following 30 days.) Drilling down even further, among the subgroup of patients with low HEART scores who were sent home without a hospital admission, the miss rate was only 0.09%. The results were so positive that Kaiser Permanente plans to adopt the system in other areas of the country that it serves. It may be coming to an ER near you.
Important: If you experience chest pain, always assume it’s medical emergency and call 911. Don’t try to diagnose yourself with HEART or any other system, and never drive yourself to the ER.