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Journal update monthly top five
  1. Daniel Horner1,2,
  2. Anthony Kelly3,
  3. Jemima Heap1,
  4. Cameron Stocks1,
  5. Eyad Tuma1,
  6. Ashley Clews1,
  7. Peter Kilgour1
  1. 1 Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK
  2. 2 Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester, UK
  3. 3 Manchester Medical School, The University of Manchester, Manchester, UK
  1. Correspondence to Dr Daniel Horner, Emergency Department, Salford Royal NHS Foundation Trust, Salford, Salford, UK; danielhorner{at}

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This month’s update is from the Emergency Department at Salford Royal NHS Foundation Trust. We used a multimodal search strategy, drawing on free open-access medical education resources and focused literature searches. We identified the five most interesting and relevant papers (decided by consensus, with editorial oversight) and highlight the main findings, key limitations and clinical bottom line for each paper.

The papers are ranked as:

  • Worth a peek—interesting, but not yet ready for prime time.

  • Head turner—new concepts.

  • Game changer—this paper could/should change practice.

External validation of a low HEAR score to identify emergency department chest pain patients at very low risk of major adverse cardiac events without troponin testing by O’Rielly et al

Topic: diagnostics

Rating: head turner

The HEART score has been widely adopted for the evaluation of atraumatic chest pain in ED patients. However, questions remain, including the additional value of risk scores over high-sensitivity troponin testing alone.1 In this secondary analysis of 1150 prospectively recruited patients, O’Reilly et al sought to externally validate the HEAR score (HEART score minus troponin) and estimate the proportion of patients who could be safely discharged from the ED without any troponin assay.2 They found that a HEAR score of ≤1 identified 17.6% of patients as very low risk for any major adverse cardiac event (MACE) up to 30 days, with a sensitivity of 99.2% (95% CI 95.6% to 99.9%).

This study excluded patients with ‘clear’ ECG evidence of ischaemia and other high-risk characteristics, limiting generalisability. The historical score component is also subjective, which raises concerns regarding inter-rater variation; this is particularly important in this secondary analysis, as the clinicians and research assistants collecting HEAR data during the initial study were not using this information to guide clinical decisions. As such, additional validation of the HEAR score in a pragmatic setting (ideally within a cluster randomised trial of diagnostic testing strategies) is essential prior to widespread adoption.

Bottom line

In this secondary analysis, a HEAR score of ≤1 identified 17.6% of patients presenting with atraumatic chest …

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  • Contributors DH completed the initial literature search and submitted article suggestions to the local editorial team and editor in chief for agreement on the top 5 articles relevant to the target audience. AK, JH, CS and ET completed initial drafts of article summaries after critical appraisal. AC and PK completed an initial draft and also provided oversight during manuscript development. DH collated all initial drafts and worked with the editorial team to peer review, revise and agree the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.