Hot off the press: SGEM#370: Listen to your HEART (score) … MACE incidence in non–low‐risk patients with known coronary artery disease

Chest pain is one of the most common presentations to the emergency department (ED), with a high admission rate in prior decades contributing to ED overcrowding. Over the years, various risk stratification systems have been developed, including the prominent HEART Score and Pathway. Patients are stratified into low, moderate, and high risk. Most “non–low-risk” patients are recommended for admission and objective cardiac testing.1-5 The study by McGinnis et al. seeks to ask if the presence of known coronary artery disease (CAD) is predictive of major adverse cardiac events (MACE) in moderate-risk patients. This study is a preplanned subgroup analysis of the HEART Pathway Implementation Study. Non–low-risk patients (history, ECG, age, risk factors [HEAR] score ≥ 4) over 21 years old with chest pain or suspected acute coronary syndrome, elevated troponin, ischemic ECG, or prior CAD were included in the study. The primary outcome was MACE at 30 days, with secondary outcomes being individual components of MACE at the index visit. In non–low-risk patients with known CAD, there was a 7.1% incidence of MACE at 30 days, and in those without known CAD, the incidence of MACE at 30 days was 1.4%. The study was limited by the fact that it was a subgroup analysis, but strengthened by the quality of the original HEART Implementation Study. The authors were clear in their definitions of MACE, and the implementation study showed that clinicians are consistent and reliable in their assignment of HEART scores. Several patients were miscategorized, which somewhat limits the data, but correct categorization would in fact make the results stronger overall. Primary outcome: 30-day MACE defined as the composite of all-cause death, myocardial infarction (MI), or coronary revascularization (including the index visit). Moderate-risk patients (HEAR score ≥ 4) without known CAD, after negative serial troponins and a nonischemic ECG, have a low 30-day risk of MACE and may be considered for outpatient workup. Non–low-risk chest pain patients with HEAR score ≥ 4 and no known CAD may be considered for discharge and close outpatient follow up. The authors declare no potential conflict of interest.