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

2. I have no disclosures, however…

3. 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

4. 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?

5. Chest pain in the emergency room: value of the HEART score Six AJ, et al. Neth Heart J 16: , 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

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

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

8. 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”

9. 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

10. 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

11. Comparison of GRACE, HEART and TIMI score to predict adverse events in CP in ED Poldervaart JM Intern J Cardiol 227: , 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

12. Comparison of GRACE, HEART and TIMI score to predict adverse events in CP in ED Poldervaart JM Intern J Cardiol 227: , 2017
GRACE HEART TIMI
95% sensitivity
low-risk ≤ ≤
% low-risk
% low-risk MACE
98% sensitivity
low-risk ≤ ≤
% low-risk
% low-risk MACE

13. 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

14. 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

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

16. HEART scores higher in more experienced providers Dubin J
HEART scores higher in more experienced providers Dubin J. Am J Em Med 35: , 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?

17. HEART score discordance between emergency physician and cardiologist Wu WK. Am J Em Med 35: , 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

18. How good is history in diagnosing ACS?
%sens %spec
Radiation both arms
Radiation to left arm
Radiation to right arm
Radiation to neck/jaw
Improvement with NTG
Similar to prior ischemia
“Typical chest pain”
Associated diaphoresis
Associated nausea
Fanaroff AC, et al. Does this patient with chest pain have ACS? The Rational
Clinical Examination Review. JAMA 314:

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