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Identifying low-risk chest pain in the emergency department without troponin testing: a validation study of the HE-MACS and HEAR risk scores
  1. Fraser Todd1,
  2. James Duff2,
  3. Edward Carlton1,3,4
  1. 1Emergency Department, North Bristol NHS Trust, Bristol, UK
  2. 2Emergency Department, Southmead Hospital, Bristol, UK
  3. 3School of Health and Social Care, University of the West of England Bristol, Bristol, UK
  4. 4University of Bristol Medical School, Bristol, UK
  1. Correspondence to Dr Fraser Todd, Emergency Department, North Bristol NHS Trust, Westbury on Trym BS10 5NB, UK; fst{at}doctors.org.uk

Abstract

Introduction Patients presenting to EDs with chest pain of possible cardiac origin represent a substantial and challenging cohort to risk stratify. Scores such as HE-MACS (History and Electrocardiogram-only Manchester Acute Coronary Syndromes decision aid) and HEAR (History, ECG, Age, Risk factors) have been developed to stratify risk without the need for troponin testing. Validation of these scores remains limited.

Methods We performed a post hoc analysis of the Limit of Detection and ECG discharge strategy randomised-controlled trial dataset (n=629; June 2018 to March 2019; 8 UK hospitals) to calculate HEAR and HE-MACS scores. A <4% risk of major adverse cardiac events (MACE) at 30 days using HE-MACS and a score of <2 calculated using HEAR defined ‘very low risk’ patients suitable for discharge. The primary outcome of MACE at 30 days was used to assess diagnostic accuracy.

Results MACE within 30 days occurred in 42/629 (7%) of the cohort. HE-MACS and HEAR scores identified 85/629 and 181/629 patients as ‘very low risk’, with MACE occurring in 0/85 and 1/181 patients, respectively. The sensitivities of each score for ruling out MACE were 100% (95% CI: 91.6% to 100%) for HE-MACS and 97.6% (95% CI: 87.7% to 99.9%) for HEAR. Presenting symptoms within these scores were poorly predictive, with only diaphoresis reaching statistical significance (OR: 4.99 (2.33 to 10.67)). Conventional cardiovascular risk factors and clinician suspicion were related to the presence of MACE at 30 days.

Conclusion HEAR and HE-MACS show potential as rule out tools for acute myocardial infarction without the need for troponin testing. However, prospective studies are required to further validate these scores.

  • acute coronary syndrome
  • acute myocardial infarct

Data availability statement

Data are available upon reasonable request. Analysis performed on the LoDED randomised controlled trial cohort published in the British Medical Journal: Heart (Carlton et al. 2020). Dataset anonymised and available upon reasonable request.

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Data availability statement

Data are available upon reasonable request. Analysis performed on the LoDED randomised controlled trial cohort published in the British Medical Journal: Heart (Carlton et al. 2020). Dataset anonymised and available upon reasonable request.

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Footnotes

  • FT and JD are joint first authors.

  • Handling editor Richard Body

  • Twitter @eddcarlton

  • Contributors FT and JD are joint first authors and participated in data collation, analysis and paper writing. EC supervised the project and provided feedback and rewrites on drafts.

  • Funding This exploratory analysis used data from the LoDED trial and received no funding. The LoDED trial was funded by the National Institute of Health Research RfPB.

  • Competing interests EC received speaker honoraria from Roche Diagnostics.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

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

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