3, 4, 5 Refer to Table 1 for a depiction of the HEART score, its five categories of variables, and scoring. 3 In these two higher score categories, two distinct subpopulations were noted, including the following MACE rates: moderate-risk, with a score of 4–6, MACE rate of approximately 12–17% and the potential consideration of observation and further testing and high-risk, with score of 7–10, MACE rate of approximately 50–65%, and the consideration of urgent or emergent intervention. 3, 4, 5 These low-risk patients were categorized as appropriate and safe for ED discharge without additional cardiac evaluation or inpatient admission conversely, a higher score was associated with an increased MACE rate and warranted more additional evaluation and/or intervention. Low-risk patients (a score 3 or less) were found to have a low (1.7%) MACE rate. Scoring ranges from 0 to 2 in each of these five categories, with the lowest possible score of 0 and the highest possible score of 10. Based upon five different variables, a score is summed for the patient under evaluation, including history (H), 12-lead electrocardiogram (ECG E), age (A), risk factors (R), and troponin (T).
Suspected ACS patients are evaluated with a standard ED focused history and evaluation. 3 This decision tool is considered rather valuable for several reasons, including its ease of application, ready availability of the variables under consideration, the focus on short-term outcome, appropriate for ED management, and the identification of three discrete sub-populations (low-, moderate-, and high-risk) of ED chest pain patients suspected of ACS. The HEART score was developed in the Netherlands in 2008 by Six, Backus and Kelder as a rapid risk stratification tool for patients with chest pain according to their short-term risk MACE (defined as acute myocardial infarction, need for percutaneous coronary intervention or coronary artery bypass graft, and death within 6 weeks ) to help identify low-risk patients, suitable for earlier ED discharge within 30 days of index ED visit. As is true of all such clinical decision rules, the physician should consider the information provided the HEART score yet exercise clinical judgment in the ultimate determination of management strategy in the adult chest pain patient suspected of ACS. The HEART score identifies patients at low, intermediate, and high risk for short-term adverse outcome resulting from ACS. The HEART score, a recently derived clinical decision rule aimed at the identification of risk in the undifferentiated chest pain patient, is potentially quite useful as an adjunct to physician medical decision-making. Many of these patients are low risk and can be managed non-urgently in the outpatient environment other patients, however, are intermediate to high risk for ACS and should be managed more aggressively, likely with inpatient admission and cardiology consultation.
The challenge of acute coronary syndrome (ACS) identification with appropriate disposition is quite significant. Chest pain is one of the most common, potentially serious presenting complaints for adult emergency department (ED) visits.
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