The HEART score for chest pain patients

B.E. Backus

Research output: ThesisDoctoral thesis 1 (Research UU / Graduation UU)

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Abstract

The HEART score was developed to improve risk stratification in chest pain patients in the emergency department (ED). This thesis describes series of validation studies of the HEART score and sub studies for individual elements of the score. The predictive value of the HEART score for the occurrence of major cardiovascular events (MACE) in chest pain patients in the ED has been determined in a series of four scientific investigations: two retrospective and two prospective studies, mostly multi center. The HEART score appears a strong predictor of event free survival on one hand and potentially life threatening cardiac events on the other hand. The HEART score helps in making accurate decisions in the ED without the use of X-rays or invasive procedures. Within one hour from presentation, it identifies both (i) a large proportion of low-risk patients, with a risk of MACE of only 1.9%, and (ii) high-risk patients, with a risk of MACE of about 50%. In case of intermediate values, the HEART score is less helpful. The HEART score is an easy, quick, and reliable predictor of outcome in chest pain patients, and may be used for triage. We investigated whether the diagnostic performance of the HEART score could be improved after redesigning based on multivariable regression analysis. We showed that the arbitrarily chosen weights of the five elements of the HEART score leave room for improvement. The improvement is relatively small with more low risk patients categorized in the intermediate risk group. Application of the adjusted HEART score results in a small fraction of diseased patients who may receive urgent treatment earlier. Hence, medical consumption in non-diseased patients will increase. This regression analysis supports the easy-to-use HEART score with an equal distribution of values given for the five elements. We investigated whether the HEART score could be beneficial in reducing this medical consumption. In particular in patients with low HEART scores, hospital admissions and specific diagnostic procedures may be reduced. Avoiding redundant medical care may result in a reduction of iatrogenic damage and cost. Theoretically, annual savings for the national health care system in The Netherlands may exceed ten million Euros. We investigated the additional value of a second troponin measurement or a cycle exercise ECG in chest pain patients in whom the HEART score was determined. A second troponin measurement results in a slight improvement of the HEART-score to discriminate patients with and without MACE, however, the clinical value of the exercise ECG in this setting is still a matter of debate. In summary, the HEART score is easy to calculate and applicable to all chest pain patients within one hour after presentation in the ED. Various approaches to improving the HEART score appear to be disappointing. The studies described in this thesis provide a better view on the approach of chest pain patients in the ED. Our results support the use of the HEART score for early risk stratification of chest pain patients and may result in a reduction of diagnostic procedures and related cost.
Original languageEnglish
QualificationDoctor of Philosophy
Awarding Institution
  • Utrecht University
Supervisors/Advisors
  • Doevendans, Pieter, Primary supervisor
  • Six, A.J., Co-supervisor, External person
Award date20 Jun 2012
Publisher
Print ISBNs978-90-8891-419-5
Publication statusPublished - 20 Jun 2012

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