Risk Stratification of Chest Pain: Best Practices Susan P. Torrey, MD, FAAEM, FACEP Associate Professor of Emergency Medicine UMass Medical School – Baystate Medical Center

I have no disclosures, however… www.TorreyEKG.com

Current practice varies Up to 6% of ED visits are chest pain related Of these <25% will have ACS The ability to identify low-risk patients in ED Reduce length of stay in ED Reduce hospitalizations and cost Improve patient statisfaction Guidelines recommend utility of risk stratification tool TIMI GRACE HEART

What is appropriate disposition? Clinical case 58-year-old man with left anterior chest pain x 1 hr, no radiation, no associated symptoms PMH: HTN, hyperlipidemia, s/p cholecystectomy EKG: sinus rhythm, normal axis and intervals, no LVH, no acute ischemia or infarct patterns Routine labs, including troponin, are normal What is appropriate disposition?

Chest pain in the emergency room: value of the HEART score Six AJ, et al. Neth Heart J 16:191-196, 2008 120 pts with chest pain followed for endpoints Acute MI PCI CABG Death Followup – 423 ± 106 days 29 pts reached endpoint – all within 3 months

HEART Score History - slight, mod, highly suspicious - 0, 1, 2 EKG - normal - 0 - nonspecific repolarization - 1 - significant ST depressions - 2 Age - <45, 45-65, >65 - 0, 1, 2 Risk - 0, 1-2, ≥3 or hx atherosclerosis - 0, 1, 2 Trop - ≤ nl, 1-2x nl, > 2x nl - 0, 1, 2

Chest pain in the emergency room: value of the HEART score Six AJ, et al. Neth Heart J 16:191-196, 2008 Score predicts endpoint and need for admission ≤ 3 points - 2.5% risk - early discharge 4-6 points - 20.3% - admit as ACS ≥ 7 points - 72.7% - “aggressive Rx”

HEART score for chest pain in ED: a multinational validation study Six AJ, et al. Crit Pathways Cardiol 12:121, 2013 HEART ≤ 3 in 820/2906 patients (28%) 6-week MACE in 1.7% (12 NSTEMI, 2 PCI) Powerful clinical tool Determines risk of 30-day MACE Quickly identifies large group of “low-risk”

Prospective validation of HEART score Backus BE, Six AJ, et al Prospective validation of HEART score Backus BE, Six AJ, et al. Int J Card 168:2153, 2013 HEART

HEART score = 3 Clinical case 58-year old man with anterior chest pain x 1 hour, no radiation, no associated symptoms PMH: HTN, hyperlipidemia, s/p cholecystectomy EKG: sinus rhythm, normal axis and intervals, no LVH, no acute ischemia or infarct patterns Routine labs, including troponin, are normal HEART score = 3

Comparison of GRACE, HEART and TIMI score to predict adverse events in CP in ED Poldervaart JM Intern J Cardiol 227:656-661, 2017 1748 ED pts over 1 year in The Netherlands Major adverse cardiac event (MACE) in 6 wks Unstable angina, NSTEMI, STEMI PCI, CABG, death of any cause GRACE ided 231 “low risk” – missed 2.2% MACE HEART ided 381 “low risk” – missed 0.8% MACE TIMI ided no “low risk” patients

Comparison of GRACE, HEART and TIMI score to predict adverse events in CP in ED Poldervaart JM Intern J Cardiol 227:656-661, 2017 GRACE HEART TIMI 95% sensitivity low-risk ≤ 72 ≤ 3 0 % low-risk 19 40 25 % low-risk MACE 3.6 2.0 3.2 98% sensitivity low-risk ≤ 66 ≤ 2 - % low-risk 13 21 - % low-risk MACE 2.2 0.8 -

Grace Score Global Registry of Acute Coronary Events Age Heart rate Systolic BP Creatinine Killip class (CHF) Cardiac arrest ST-segment deviation  cardiac enzymes Consider discharge if < 80 points = 87

TIMI Age > 65 years Known stenosis > 50% Elevated cardiac enzyme ≥ 3 risk factors ASA use ≥ 2 episodes angina in 24 hours ST depression ≥ 0.5mm Score 1 point per positive criteria Consider discharge if score = 0 and negative enzymes

HEART scores higher in more experienced providers Dubin J HEART scores higher in more experienced providers Dubin J. Am J Em Med 35:122-125, 2017. 28% patients “low risk” (score ≤ 3) MACE rate – 2% Years ED experience: 0-5 vs 10-15 Mean HEART admit 3.93 4.65 MACE rates 5.6% 15.3% % low risk admits 39% 25%

HEART scores higher in more experienced providers Dubin J HEART scores higher in more experienced providers Dubin J. Am J Em Med 35:122-125, 2017. More experience admitted higher-risk patients and more likely to admit patient with MACE Change in clinical gestalt with experience? Difference in risk perception? Difference in risk tolerance?

HEART score discordance between emergency physician and cardiologist Wu WK. Am J Em Med 35: 132-135, 2017. Triage cardiology program 33 patients evaluated by ED and cards 23 (70%) had discordant scores Discrepancy in description of chest pain common ED provider overestimated score of cardiology 25% of pt classified high risk by ED / low risk by cards

How good is history in diagnosing ACS? %sens %spec Radiation both arms 11 96 Radiation to left arm 40 69 Radiation to right arm 5 96 Radiation to neck/jaw 24 84 Improvement with NTG 71 35 Similar to prior ischemia 47 79 “Typical chest pain” 68 66 Associated diaphoresis 26 80 Associated nausea 22 80 Fanaroff AC, et al. Does this patient with chest pain have ACS? The Rational Clinical Examination Review. JAMA 314:1955. 2015

HEART score and clinical gestalt have similar diagnostic accuracy for ACS Visser A, et al. Emerg Med J 32:595, 2015.