The HEART score was noninferior to usual care in patients with chest pain, with an adjusted absolute difference in 6-week major adverse cardiac events of -1.3% (within the 3.0% margin).
RCT (n=3,648)
Open-label
Stepped-wedge cluster randomized
Yes
Does using the HEART score to guide management safely reduce health care resource use in unselected patients with chest pain in the emergency department?
Implementation of the HEART score in the emergency department is safe for chest pain triage, but its impact on resource utilization may be limited by physician adherence to low-risk recommendations.
Effect estimate: Absolute difference -1.3% (95% CI upper limit 2.1)
Absolute Event Rate: 18.9% vs 22.2%
BACKGROUND: The HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score is an easy-to-apply instrument to stratify patients with chest pain according to their short-term risk for major adverse cardiac events (MACEs), but its effect on daily practice is unknown. OBJECTIVE: To measure the effect of use of the HEART score on patient outcomes and use of health care resources. DESIGN: Stepped-wedge, cluster randomized trial. (ClinicalTrials.gov: NCT01756846). SETTING: Emergency departments in 9 Dutch hospitals. PATIENTS: Unselected patients with chest pain presenting at emergency departments in 2013 and 2014. INTERVENTION: All hospitals started with usual care. Every 6 weeks, 1 hospital was randomly assigned to switch to "HEART care," during which physicians calculated the HEART score to guide patient management. MEASUREMENTS: For safety, a noninferiority margin of a 3.0% absolute increase in MACEs within 6 weeks was set. Other outcomes included use of health care resources, quality of life, and cost-effectiveness. RESULTS: A total of 3648 patients were included (1827 receiving usual care and 1821 receiving HEART care). Six-week incidence of MACEs during HEART care was 1.3% lower than during usual care (upper limit of the 1-sided 95% CI, 2.1% within the noninferiority margin of 3.0%). In low-risk patients, incidence of MACEs was 2.0% (95% CI, 1.2% to 3.3%). No statistically significant differences in early discharge, readmissions, recurrent emergency department visits, outpatient visits, or visits to general practitioners were observed. LIMITATION: Physicians were hesitant to refrain from admission and diagnostic tests in patients classified as low risk by the HEART score. CONCLUSION: Using the HEART score during initial assessment of patients with chest pain is safe, but the effect on health care resources is limited, possibly due to nonadherence to management recommendations. PRIMARY FUNDING SOURCE: Netherlands Organisation for Health Research and Development.
Poldervaart et al. (Tue,) conducted a rct in Chest pain (n=3,648). HEART score vs. Usual care was evaluated on Major adverse cardiac events (MACEs) within 6 weeks (Absolute difference -1.3%, 95% CI upper limit 2.1). The HEART score was noninferior to usual care in patients with chest pain, with an adjusted absolute difference in 6-week major adverse cardiac events of -1.3% (within the 3.0% margin).