Off-hours presentation resulted in clinically similar HEART score discrimination for 30-day major adverse cardiac events compared to on-hours presentation, with an AUC difference of +0.009.
Cohort (n=2,800)
No
Does the HEART score perform similarly in discriminating 30-day MACE risk for emergency department chest pain presentations during off-hours compared to on-hours?
The HEART score demonstrates clinically similar discrimination for 30-day MACE regardless of presentation time, supporting its consistent use in emergency department triage.
Effect estimate: ΔAUC +0.009 (95% CI -0.041 to +0.058)
Absolute Event Rate: 0.83% vs 0.821%
p-value: p=0.736
Abstract Aims We compared HEART score discriminative performance and calibration for 30-day major adverse cardiac events (MACE) between off-hours and on-hours emergency department chest pain presentations. Methods A single-center retrospective cohort study was conducted at Istanbul Medipol Mega University Hospital from January 2020 through December 2025, enrolling 2,800 patients (off-hours n = 2,133; on-hours n = 667). Off-hours comprised evenings, nights, weekends, and public holidays. The primary outcome was 30-day MACE, defined as acute myocardial infarction, unplanned coronary revascularization, cardiac arrest, or all-cause death. Discrimination was compared by the DeLong method; an absolute between-group AUC difference below 0.08, set a priori, was used as the margin of clinical similarity. Calibration was assessed by the Hosmer-Lemeshow test, observed-to-expected ratio, and calibration slope. Results 30-day MACE occurred in 14.4% of 2,800 patients. The HEART score AUC was 0.830 (95% CI 0.805–0.855) in off-hours and 0.821 (95% CI 0.778–0.865) in on-hours patients; ΔAUC was + 0.009 (95% CI -0.041 to + 0.058; p = 0.736), with the confidence interval contained within the a priori margin. At the rule-out threshold (HEART ≥ 4), off-hours sensitivity was 95.7% (95% CI 92.8–97.5%) and negative predictive value (NPV) was 97.7% (95% CI 96.2–98.7%). No differential shift effect was detected (interaction OR 1.039; 95% CI 0.867–1.247; p = 0.676). Both groups demonstrated systematic overestimation of absolute MACE risk relative to Backus 2013 probabilities (off-hours calibration intercept − 0.352; 95% CI -0.495 to -0.208; p < 0.001), with no between-group difference ( p = 0.998). Conclusion The HEART score showed clinically similar discrimination for 30-day MACE regardless of presentation time, supporting its use across different presentation times in tertiary-care settings with comparable infrastructure, pending prospective multicenter confirmation. Local recalibration of absolute risk estimates should be considered before probability-guided triage protocols are implemented in comparable settings.
Kurt et al. (Wed,) conducted a cohort in Emergency chest pain (n=2,800). Off-hours presentation vs. On-hours presentation was evaluated on Discrimination for 30-day major adverse cardiac events (AUC) (ΔAUC +0.009, 95% CI -0.041 to +0.058, p=0.736). Off-hours presentation resulted in clinically similar HEART score discrimination for 30-day major adverse cardiac events compared to on-hours presentation, with an AUC difference of +0.009.
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