Key result
The HEART-GP score, which incorporates the physician's sense of alarm, demonstrated high diagnostic accuracy for predicting 6-week major adverse cardiac events with a C-statistic of 0.90.
Why the study?
Distinguishing urgent from non-urgent causes of chest pain in urgent primary care is challenging, and modified HEART scores omitting or replacing troponin may aid in risk stratification.
Does a simplified HEART score or HEART-GP score improve diagnostic accuracy and risk stratification for chest pain in urgent primary care compared to unaided physician assessment?
Cohort (n=664)
No
Does a simplified HEART score or HEART-GP score improve diagnostic accuracy and risk stratification for chest pain in urgent primary care compared to unaided physician assessment?
Effect estimate: C-statistic 0.90 (95% CI 0.85-0.95)
Modified HEART scores omitting troponin and incorporating physician 'sense of alarm' show good diagnostic accuracy for chest pain in primary care and may improve safety over unaided clinical judgment, though at the cost of increased referrals.
Modified HEART scores showed high NPV for chest pain in primary care; leaves open need for prospective validation before changing triage practice.
BACKGROUND: Chest pain is a common symptom in urgent primary care. The distinction between urgent and non-urgent causes can be challenging. A modified version of the HEART score, in which troponin is omitted ('simplified HEART') or replaced by the so-called 'sense of alarm' (HEART-GP), may aid in risk stratification. METHOD: This study involved a retrospective, observational cohort of consecutive patients evaluated for chest pain at a large-scale, out-of-hours, regional primary care facility in the Netherlands, with 6‑week follow-up for major adverse cardiac events (MACEs). The outcome of interest is diagnostic accuracy, including positive predictive value (PPV) and negative predictive value (NPV). RESULTS: We included 664 patients; MACEs occurred in 4.8% (n = 32). For simplified HEART and HEART-GP, we found C‑statistics of 0.86 (95% confidence interval (CI) 0.80-0.91) and 0.90 (95% CI 0.85-0.95), respectively. Optimal diagnostic accuracy was found for a simplified HEART score ≥2 (PPV 9%, NPV 99.7%), HEART-GP score ≥3 (PPV 11%, NPV 99.7%) and HEART-GP score ≥4 (PPV 16%, NPV 99.4%). Physicians referred 157 patients (23.6%) and missed 6 MACEs. A simplified HEART score ≥2 would have picked up 5 cases, at the expense of 332 referrals (50.0%, p < 0.001). A HEART-GP score of ≥3 and ≥4 would have detected 5 and 3 MACEs and led to 293 (44.1%, p < 0.001) and 186 (28.0%, p = 0.18) referrals, respectively. CONCLUSION: HEART-score modifications including the physicians' 'sense of alarm' may be used as a risk stratification tool for chest pain in primary care in the absence of routine access to troponin assays. Further validation is warranted.
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Harskamp et al. (2021) conducted a cohort in Chest pain (n=664). HEART-GP score vs. Unaided clinical judgement was evaluated on Diagnostic accuracy (C-statistic) for major adverse cardiac events at 6 weeks (C-statistic 0.90, 95% CI 0.85-0.95). The HEART-GP score, which incorporates the physician's sense of alarm, demonstrated high diagnostic accuracy for predicting 6-week major adverse cardiac events with a C-statistic of 0.90.
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