In emergency department (ED) visits, chest pain is the second most common reason, accounting for 5% of all annual encounters, of which only 10% have an acute coronary syndrome (ACS). Some patients that are considered “low risk” still have major adverse cardiovascular event (MACE) that prompted development of a number of risk scoring systems in this group.
African Americans (AA) are understudied with respect to risk scoring of CV events when compared to whites and differential use of coronary revascularization may contribute to the poorer functional outcomes observed among AA patients with documented coronary disease. This study utilized history, electrocardiogram, age, risk factors, and initial troponin (HEART) and thrombolysis in myocardial infarction (TIMI) scores to predict major adverse cardiovascular events (MACE) in non-high cardiovascular (CV) risk predominantly AA patient population.
A retrospective emergency department (ED) charts review of 1266 chest pain patients where HEART and TIMI scores were calculated for each patient. Logistic regression model was computed to predict 6-week and 1-year MACE and 90-day cardiac readmission. Decision curve analysis (DCA) was constructed to differentiate between clinical strategies in non-high CV risk patients.
Of the 817 patients included, 500 patients had low HEART score and 317 patients had moderate HEART score. Six hundred sixty-three patients had low TIMI score and 154 patients had high TIMI score.
Four hundred eighty-four patients were found to fall under both low TIMI and low HEART score category and 138 patients were classified under both high TIMI and moderate HEART score category.
Of the 817 patients, 6 patients had MACE and 100 patients had cardiac readmission. The univariate logistic regression model shows odds ratio of predicting 6-week MACE using HEART score was 3.11 (95% confidence interval [CI] 1.43–6.76, P?=?.004) with increase in risk category from low to moderate vs. 2.07 (95% CI 1.18–3.63, P?=?.011) using TIMI score with increase in risk category from low to high and c-statistic of 0.86 vs. 0.79, respectively. DCA showed net benefit of using HEART score is equally predictive of 6-week MACE when compared to TIMI.
In non-high CV risk AA patients, HEART score is better predictive tool for 6-week MACE when compared to TIMI score. Furthermore, patients presenting to ED with chest pain, the optimal strategy for a 2% to 4% miss rate threshold probability should be to discharge these patients from the ED.
The study suggests, HEART score has better overall discrimination than the TIMI score to predict 6-week MACE in non-high CV risk AA population, consistent with prior reports. This study also demonstrated that both TIMI and HEART score could moderately discriminate patients for 1-year MACE and 90-day cardiac readmission outcomes.
The HEART score allows clinicians to immediately decide about the treatment plan in the ED. Almost two thirds of the patients in our cohort were “low” risk with HEART score 0 to 3, and none of them had MACE during 6-week follow-up. These findings will allow clinicians to avoid redundant diagnostic testing. It will allow clinicians to triage patients who will benefit from early discharge, as evidenced by DCA in our study, and others who will require additional testing with either stress testing or CT coronary angiography.