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Six years of heart score maryland 01 04

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Presentation of the past and current evidence of the HEART score for chest pain patients at the Emergency Department

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Six years of heart score maryland 01 04

  1. 1. Six years of HEART score BE Backus, MD, PhD Medical Center The Hague, Netherlands Resident Emergency Medicine
  2. 2. How it began • Risk score for chest pain patients • 5 elements • 0, 1 or 2 points • Analogue to the APGAR score
  3. 3. How it began HEART
  4. 4. How it began HEART
  5. 5. How it began HEART
  6. 6. How it began HEART
  7. 7. How it began HEART
  8. 8. History (anamnesis) Highly suspicious 2 Moderately suspicious 1 Slightly or non-suspicious 0 ECG Significant ST-deviation 2 Non specific rep disturbance / LBTB / PM 1 Normal 0 Age ≥ 65 year 2 45 – 65 year 1 ≤ 45 year 0 Risk factors ≥ 3 risk factors or history of (treated) atherosclerosis 2 1 or 2 risk factors 1 No risk factors known 0 Troponin ≥ 3x normal limit 2 1-3x normal limit 1 ≤ normal limit 0 Total HEART score for chest pain patients
  9. 9. N=120
  10. 10. C-stats 0.90 NPV 97.5%
  11. 11. Validation program of HEART
  12. 12. Accurate Compare
  13. 13. Regression analysis Troponin Exercise testing Medical Consumption Medical Consumption Single Site Retro NL Prospective NL Prospective Pacific Implement HEART Pooled Results Elderly Diabetics Women TIMI TIMI GRACE
  14. 14. All MACE Death/ AMI ACS p value HEART vs HEART 0.83 0.82 0.86 TIMI 0.75 0.70 0.78 < 0.0001 GRACE 0.70 0.71 0.72 < 0.0001 Discriminative performance (n=2388) HEART-TIMI-GRACE
  15. 15. Graphic results of three risk scores (n=2388) 0 10 20 30 40 50 60 70 80 PercentageMACE From minimum to maximum score HEART TIMI GRACE
  16. 16. Risk groups and proposed policy when using the HEART score (pooled results n=6174) HEART ~ % pts MACE/n MACE Death Proposed Policy 0-3 32% 38/1993 1.9% 0.05% Discharge 4-6 51% 413/3136 13% 1.3% Observation, risk management 7-10 17% 518/1045 50% 2.8% Observation, treatment, CAG www.heartscore.nl
  17. 17. MACE risk per HEART score (n=6174) HEART ≤ 1 0.8% 6.5% pts HEART ≤ 2 1.1% 11.4% HEART ≤ 3 1.9% 32.3% HEART ≤ 4 3.7% 51.1%
  18. 18. So HEART works, and then? EFFICIENCY PATIENT BENEFIT COST SAVING TROPONINS DIAGNOSTICS
  19. 19. ESC guidelines N-STEMI 2015
  20. 20. ESC guidelines N-STEMI 2015
  21. 21. GRACE won’t help the EP HEART will !
  22. 22. HEART regression analysis HEART HEART-adj H 0 1 2 0 3 4 E 0 1 2 0 1 2 A 0 1 2 0 2 2 R 0 1 2 0 1 1 T 0 1 2 0 2 5 Max 10 14 c-stats 0.832 0.851 Submitted
  23. 23. Higher calibration NRI 14.1% in favour of original HEART!
  24. 24. Single high sensitive troponin EW Carlton et al
  25. 25. HEART + hs troponin T or I Hs Troponin I Hs Troponin T Endpoint: AMI < 30 days
  26. 26. Study protocol
  27. 27. HEART-Impact trial: stepped wedge
  28. 28. HEART impact trial 3666 inclusions 1833 HEART intervention 3 % no HEART score 1833 Usual Care 1821 HEART intervention1827 Usual Care 18 patients FU - / drop out
  29. 29. Impact limited By non-adherence to protocol 2.0% SAFE
  30. 30. Mahler, Crit Card Qual Outc, 2015 (8), 195-203
  31. 31. HEART Pathway study • 282 patients with 141 patients in each arm of the study • HEART Pathway identified of 46.8% of patients as low risk • Zero patients identified as low risk had a MACE 0 10 20 30 40 50 60 70 80 discharge HEART discharge UC testing HEART testing UC LOS HEART LOS UC 39.7% 18.4% 56.7% 68.8% 9.9 hr 21.9 hr
  32. 32. HEART score is safe to use in chest pain patients Please follow your HEART…
  33. 33. www.heartscore.nl @barbrabackus

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