We’ve all heart about the HEART score for risk stratification of patients with chest pain in the ED. Take away the troponin and you’ve got the HEAR score!
Yes, the HEAR score tries to identify patients at very low risk of ACS that don’t even need a troponin. The thought is this will decrease resource utilisation and improve patient flow.
They conducted a secondary analysis of a prospective cohort study of patients with chest pain that got a troponin to exclude MI in their single ED.
They enrolled 1150 patients. Of those, 8% had index MI and 11% with MACE by 30 days. HEAR score <1 identified 202 (17.6%) of patients at very low risk of adverse events with a 99% sensitivity (95% CI 95.6-99.9%). Only one patient out of 202 was missed.
As with most screening tools that are highly sensitive, it often means they are terribly non-specific. The HEAR score is no exception. As such, it should only be used as a one-way decision instrument.
The authors of this study appropriately conclude that this very low risk cohort of HEAR <1 is unlikely to benefit from troponin testing and will lead to significant resource savings.
This is not exactly ground-breaking. A young patient with a low-risk story, a normal ECG, and no risk factors is very unlikely to have a problem.
Sure, it’s probably fine to skip the troponin. I think a lot of us have been doing this over the years via gestalt. But at least this study quantifies the risk and provides support for those clinicians who want to avoid troponin testing in very low risk patients.
Perhaps the greatest use of HEAR score is to allow you sleep at night… perhaps a bit of medico-legal defense when you document the score and send that low risk patient home without blood tests.
O'Rielly CM, Andruchow JE, McRae AD. External validation of a low HEAR score to identify emergency department patients at very low risk of major adverse cardiac events without troponin testing. CJEM. 2022;24:68-74. [link to article]