HEART Score for Major Cardiac Events

From Barbra Backus, MD, PhD, co-author of the HEART Score:

Why did you develop the HEART Score for Major Cardiac Events? Was there a clinical experience that inspired you to create this tool for clinicians?

The HEART score was created based on expert opinion through examination of many patients with chest pain. The structure of the five elements with a 0, +1, and +2 scoring system (analogous to the Apgar score) helps to translate a long history and examination of a patient with chest pain into a comprehensible score of 0 to 10.

What pearls, pitfalls and/or tips do you have for users of the HEART Score for Major Cardiac Events? Are there cases in which it has been applied, interpreted, or used inappropriately?

The great benefit of the HEART score is that it is applicable to all chest pain patients in the ED or ACS unit. A minor pitfall is that the user needs at least some experience taking a chest pain history and reading an ECG to interpret these two elements of the score.

I had a few questions about definitions — was troponin “on admission” the initial troponin drawn in the ER upon arrival there? Also, how did you define AMI in patients with a troponin already >3x normal? Was it AMI if the troponin continued to trend up, if no obvious EKG changes were seen?

In all our validation studies, we used the first troponin on arrival. With that single troponin value, the HEART Score has a NPV >98%. A recent study by Mahler et. al. shows that HEART ≤3 with 2 sets of negative troponin has a NPV of >99% for MACE. Of course, every decrease in risk of endpoints is desirable, but HEART with a single troponin is already a very reliable predictor of MACE/ACS.

For the definition of AMI we used the ESC guidelines. When there was any doubt (i.e., small troponin rise or concurrent arrhythmia) we would send the case to the adjudication committee for a definite risk stratification of the endpoint.

What recommendations do you have for health care providers once they have applied the HEART Score for Major Cardiac Events? Are there any adjustments or updates you would make to the score given recent changes in medicine?

The score is relatively new, so there are no major adjustments to make yet. Perhaps after we finish our current studies, we will be able to show that a HEART score with high sensitivity troponin is as good or perhaps better than the original HEART Score.

I do think that the HEART score is a very good and easy-to-use instrument for every doctor working on an ED or ACS unit. However, the HEART score is just a scoring system and every patient is different. When you have any doubt or uncanny feeling about your patient, follow this: “The HEART Score can never replace our clinical thinking and our gut feeling.”

Any other comments? Any new research or papers on this topic in the pipeline? Any thoughts on comparisons to other risk scores (GRACE, etc)?

We are about to finish our implementation study, looking at the benefits, cost-effectiveness and safety of implementing the HEART score to our ED. Within the year, we will also finish studies on the HEART score in conjunction with different sets of troponin, like HEART plus copeptin, FABP and inter-observer variability.

Finally — any interest or thought about developing your data set into continuous variables in a best-of-fit regression model? We've had a few authors who have taken their point-based scores and turned their variables into continuous ones — allowing us on the site to provide a better outcome estimate for users. (I've also been told these are great for publication, too.)

We did perform regression analysis on the HEART score. I hope the results will be published soon. I do think that a continuous scoring with corresponding risk could be helpful for many clinicians. For example, helping clinicians to figure out the risk a patient has for potential MACE/ACS with a HEART score of 4 or 6, instead of the groups 0-3, 4-6 and 7-10.

Barbra Backus, MD, PhD, worked as a junior cardiologist under Dr. Six prior to her work on the HEART Studies. After completing her PhD, she began a residency in Emergency Medicine at the Albert Schweitzer Hospital in Dordrecht in the Netherlands. Her main research focus is on risk stratification of ACS.