Hospital Admission Despite Low-Risk History, Electrocardiogram, Age, Risk factors, and Troponin (HEART) Scores and 30-Day Outcomes in Emergency Department Chest Pain

Q: What are the key findings of this study?

Among emergency department patients with low-risk HEART scores, clinician override (hospital admission) was independently associated with higher odds of 30-day MACE (adjusted OR 5.16) compared to discharge.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Emergency department chest pain with low-risk HEART score (<4) (n=33392). Intervention: Clinician override (hospital admission despite low-risk HEART score) vs. Discharged from the emergency department. Primary outcome: 30-day major adverse cardiovascular events (MACE), defined as myocardial infarction, coronary revascularization, or all-cause mortality (adjusted OR 5.16, 95% CI 3.40 to 7.82).

Q: What does this research mean for the field?

Clinician override to admit emergency department patients with low-risk HEART scores identifies a subgroup at significantly higher risk for 30-day major adverse cardiovascular events, providing prognostic value beyond the clinical score alone. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To evaluate whether admitting emergency department patients with low-risk HEART scores identifies a subgroup at higher risk for 30-day major adverse cardiovascular events and provides prognostic information beyond the score alone.

Hao Wang; Eric Chou; Richard D. Robinson; Nicholas Saltarelli; Garrett Johnson; Sarah Merchant; Emily Morales; Jessica J. Kirby

doi:10.1016/j.acepjo.2026.100502

September 4, 2026Journal of the American College of Emergency Physicians OpenOpen Access

Hospital Admission Despite Low-Risk History, Electrocardiogram, Age, Risk factors, and Troponin (HEART) Scores and 30-Day Outcomes in Emergency Department Chest Pain

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Key result

Clinician override of low-risk HEART scores linked to ~5-fold higher 30-day MACE.

adjusted OR 5.16
95% CI 3.40 to 7.82
n=33,392

Figures

Why the study?

To evaluate whether hospital admission of emergency department patients despite low-risk HEART scores (<4) identifies a subgroup at higher risk for 30-day MACE and whether clinician override provides prognostic information beyond the score.

Does clinician override (hospital admission) identify a higher risk of 30-day MACE in emergency department patients with chest pain and low-risk HEART scores compared to discharge?

Key Points

To evaluate whether admitting emergency department patients with low-risk HEART scores identifies a subgroup at higher risk for 30-day major adverse cardiovascular events and provides prognostic information beyond the score alone.
Retrospective, multicenter observational study across 6 emergency departments from January 1, 2021, through December 31, 2023.
Included 33,392 adult patients presenting with chest pain who had low-risk HEART scores (<4), defining clinician override as hospital admission despite the low-risk classification.
Assessed 30-day major adverse cardiovascular events (all-cause mortality, myocardial infarction, or coronary revascularization) using multivariable logistic regression adjusted for demographic, clinical, and laboratory covariates.
Clinician override occurred in 2101 of 33,392 patients (6.3%), with 30-day major adverse cardiovascular events occurring in 40 of 2101 admitted patients (1.90%) compared to 80 of 31,291 discharged patients (0.26%).
Clinician override was independently associated with significantly higher odds of 30-day major adverse cardiovascular events (adjusted odds ratio, 5.16; 95% CI, 3.40 to 7.82).
Adding clinician override to the baseline clinical model significantly improved risk discrimination (AUROC, 0.8006 vs. 0.8287; DeLong P = .0026; likelihood ratio χ2 = 49.82, P < .001).

Study Design

Type

Cohort (n=33,392)

Multicenter

Yes

Structured PICO

Does clinician override (hospital admission) identify a higher risk of 30-day MACE in emergency department patients with chest pain and low-risk HEART scores compared to discharge?

P

Population

33,392 adult patients presenting to the emergency department with chest pain and a low-risk HEART score (<4), followed for 30 days.

E

Exposure

Clinician override (hospital admission despite a low-risk HEART score <4)

C

Comparator

No clinician override (discharge from the emergency department with a low-risk HEART score <4)

O

Outcome

30-day MACE (composite of acute myocardial infarction, coronary revascularization [percutaneous coronary intervention or coronary artery bypass grafting], or all-cause mortality occurring within 30 days of the index ED visit)composite

Main Result

Odds Ratio: 5.16 (95% CI 3.4–7.82)

Absolute Event Rate: 1.9% vs 0.26%

Clinician override of low-risk HEART scores in the emergency department identifies a subgroup of patients at substantially higher risk for 30-day major adverse cardiovascular events, providing incremental prognostic value beyond structured risk scores.

Limitations

Residual confounding from unmeasured diagnoses and other clinical factors influencing disposition
Composite MACE outcome included coronary revascularization, which may be influenced by admission decisions
Incomplete outcome ascertainment for events or deaths occurring outside the health system
Potential selection bias due to non-uniform HEART score documentation
Limited generalizability as all sites were within a single health system
Retrospective observational study with potential residual confounding from unmeasured diagnoses and clinical factors
HEART scores were based on clinician-entered values and not independently recalculated or verified
Composite MACE outcome included coronary revascularization, which may be influenced by admission decisions and subsequent diagnostic testing
Inclusion limited to encounters with documented HEART scores, introducing potential selection bias
All sites were within a single health system, which may limit generalizability

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Answers are grounded in this paper and cite their sources.

Implication

Override flags higher MACE risk beyond HEART score; hypothesis-generating and should not yet change discharge practice.

Abstract

Objective To evaluate whether hospital admission of emergency department (ED) patients despite low-risk History, Electrocardiogram, Age, Risk factors, and Troponin (HEART) scores (<4) identifies a subgroup at higher risk for 30-day major adverse cardiovascular events (MACE) and to determine whether clinician override provides prognostic information beyond the HEART score. Methods We conducted a retrospective, multicenter observational study across 6 EDs from January 1, 2021, through December 31, 2023. Adult patients presenting with chest pain and a documented HEART score were included. Analyses were restricted to first encounters among patients with low-risk HEART scores (<4). Clinician override was defined as hospital admission despite low-risk classification. The primary outcome was 30-day MACE, defined as myocardial infarction (MI), coronary revascularization, or all-cause mortality. Multivariable logistic regression identified factors associated with clinician override and evaluated the independent association between clinician override and 30-day MACE after adjustment for age, sex, race or ethnicity, study site, HEART score variables, troponin trend, chronic heart failure, and chronic kidney disease. Incremental prognostic value was assessed using the likelihood ratio and DeLong tests. Results Among 33,392 patients with low-risk HEART scores, clinician override occurred in 2101 (6.3%). Thirty-day MACE occurred in 120 patients (0.36%), including 40 of 2101 admitted patients (1.90%) and 80 of 31,291 discharged patients (0.26%). Clinician override was independently associated with higher odds of 30-day MACE (adjusted odds ratio, 5.16; 95% CI, 3.40 to 7.82). Clinician override significantly improved prediction of 30-day MACE beyond the baseline clinical model (AUROC, 0.8006 vs. 0.8287; DeLong P = .0026; likelihood ratio χ 2 = 49.82, P <.001). Conclusion Among ED patients with low-risk HEART scores, clinician override was uncommon but identified a subgroup at substantially higher risk for 30-day MACE. Although clinician override was largely associated with measurable clinical characteristics, it provided incremental prognostic information beyond the HEART score and major comorbidities, supporting the complementary role of clinician judgment in risk stratification.

Discussion

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Cite This Study

Wang et al. (2026) conducted a cohort in Emergency department chest pain with low-risk HEART score (<4) (n=33,392). Clinician override (hospital admission despite low-risk HEART score) vs. Discharged from the emergency department was evaluated on 30-day major adverse cardiovascular events (MACE), defined as myocardial infarction, coronary revascularization, or all-cause mortality (adjusted OR 5.16, 95% CI 3.40 to 7.82). Among emergency department patients with low-risk HEART scores, clinician override (hospital admission) was independently associated with higher odds of 30-day MACE (adjusted OR 5.16) compared to discharge.

synapsesocial.com/papers/6a9d1e3328139818eab20fc4 https://doi.org/10.1016/j.acepjo.2026.100502

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Hospital Admission Despite Low-Risk History, Electrocardiogram, Age, Risk factors, and Troponin (HEART) Scores and 30-Day Outcomes in Emergency Department Chest Pain

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Hospital Admission Despite Low-Risk History, Electrocardiogram, Age, Risk factors, and Troponin (HEART) Scores and 30-Day Outcomes in Emergency Department Chest Pain

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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