A couple posts ago I mentioned it was time for the TIMI Risk Score for UA/nSTEMI to go the way of the dodo for evaluation of chest pain in the Emergency Department. It wasn't derived from an Emergency Department population, doesn't have great predictive skill in identifying very-low-risk patients, and includes nonsensical elements (did you take an aspirin within the last 7 days?).
Alternatively, we have the HEART score: History, ECG, Age, Risk factors, Troponin. This was derived – like the Wells score – from the elements of clinical gestalt, and ought to at least make better intuitive sense than the occasionally frizzy outputs from multivariate logistic regression. It was initially derived and refined retrospectively, and this represents the prospective validation study. These authors prospectively enrolled 2,440 patients from 10 centers in the Netherlands and followed them for a primary endpoint of a major adverse cardiac event (AMI, PCI, CABG, death) for six weeks. They also collected the variables of interest necessary to calculate TIMI and GRACE risk scores for comparison of c-statistic.
Obviously, I'm recommending the HEART score because it outperformed the others – the c-statistic for HEART was 0.83, 0.75 for TIMI, and 0.70 for GRACE. Most importantly, for the Emergency Department, it was superior at the low-end of the spectrum. For the 34% of the population that was TIMI 0-1, 23/811 (2.8%) had 6-week MACE. 14.0% had GRACE 0-60, and 10/335 (2.9%) had MACE. For HEART, 36.4% were 0-3 and ultimately 15/870 (1.7%) had MACE.
Even though there are 2,400 patients in this study, there are few enough in each individual category that confidence intervals for each predictive bucket are still relatively wide. Then, you can still have a HEART score in the "very low risk" 0-3 range with a troponin >3x the normal limit and an abnormal EKG – which is seemingly counterintuitive. They also don't compare their rule to clinical judgment, so we can't measure the performance of the rule in actual decision-making.
A couple other studies have either prospectively or retrospectively validated these findings with reasonable consistency. It isn't perfect – but it's better than TIMI or GRACE – and it's what I currently use to support my shared decision-making discussions at disposition of the appropriate chest pain cohort.
"A prospective validation of the HEART score for chest pain patients at the emergency department"