R E Harskamp1,2, M Kleton3, I H Smits3, A Manten3, J C L Himmelreich3, H C P M van Weert3, R P Rietveld4,5, W A M Lucassen3,6. 1. Department of General Practice, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences and Amsterdam Public Health Research Institutes, Academic Medical Centre, Amsterdam, The Netherlands. r.e.harskamp@gmail.com. 2. Holendrecht Medical Center, Amsterdam, The Netherlands. r.e.harskamp@gmail.com. 3. Department of General Practice, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences and Amsterdam Public Health Research Institutes, Academic Medical Centre, Amsterdam, The Netherlands. 4. Huisartsenorganisatie Noord-Kennemerland, Alkmaar, The Netherlands. 5. Huisartsen Centrumwaard, Heerhugowaard, The Netherlands. 6. Huisartsen Risdam, Zwaag, The Netherlands.
Abstract
BACKGROUND: Chest pain is a common symptom in urgent primary care. The distinction between urgent and non-urgent causes can be challenging. A modified version of the HEART score, in which troponin is omitted ('simplified HEART') or replaced by the so-called 'sense of alarm' (HEART-GP), may aid in risk stratification. METHOD: This study involved a retrospective, observational cohort of consecutive patients evaluated for chest pain at a large-scale, out-of-hours, regional primary care facility in the Netherlands, with 6‑week follow-up for major adverse cardiac events (MACEs). The outcome of interest is diagnostic accuracy, including positive predictive value (PPV) and negative predictive value (NPV). RESULTS: We included 664 patients; MACEs occurred in 4.8% (n = 32). For simplified HEART and HEART-GP, we found C‑statistics of 0.86 (95% confidence interval (CI) 0.80-0.91) and 0.90 (95% CI 0.85-0.95), respectively. Optimal diagnostic accuracy was found for a simplified HEART score ≥2 (PPV 9%, NPV 99.7%), HEART-GP score ≥3 (PPV 11%, NPV 99.7%) and HEART-GP score ≥4 (PPV 16%, NPV 99.4%). Physicians referred 157 patients (23.6%) and missed 6 MACEs. A simplified HEART score ≥2 would have picked up 5 cases, at the expense of 332 referrals (50.0%, p < 0.001). A HEART-GP score of ≥3 and ≥4 would have detected 5 and 3 MACEs and led to 293 (44.1%, p < 0.001) and 186 (28.0%, p = 0.18) referrals, respectively. CONCLUSION: HEART-score modifications including the physicians' 'sense of alarm' may be used as a risk stratification tool for chest pain in primary care in the absence of routine access to troponin assays. Further validation is warranted.
BACKGROUND:Chest pain is a common symptom in urgent primary care. The distinction between urgent and non-urgent causes can be challenging. A modified version of the HEART score, in which troponin is omitted ('simplified HEART') or replaced by the so-called 'sense of alarm' (HEART-GP), may aid in risk stratification. METHOD: This study involved a retrospective, observational cohort of consecutive patients evaluated for chest pain at a large-scale, out-of-hours, regional primary care facility in the Netherlands, with 6‑week follow-up for major adverse cardiac events (MACEs). The outcome of interest is diagnostic accuracy, including positive predictive value (PPV) and negative predictive value (NPV). RESULTS: We included 664 patients; MACEs occurred in 4.8% (n = 32). For simplified HEART and HEART-GP, we found C‑statistics of 0.86 (95% confidence interval (CI) 0.80-0.91) and 0.90 (95% CI 0.85-0.95), respectively. Optimal diagnostic accuracy was found for a simplified HEART score ≥2 (PPV 9%, NPV 99.7%), HEART-GP score ≥3 (PPV 11%, NPV 99.7%) and HEART-GP score ≥4 (PPV 16%, NPV 99.4%). Physicians referred 157 patients (23.6%) and missed 6 MACEs. A simplified HEART score ≥2 would have picked up 5 cases, at the expense of 332 referrals (50.0%, p < 0.001). A HEART-GP score of ≥3 and ≥4 would have detected 5 and 3 MACEs and led to 293 (44.1%, p < 0.001) and 186 (28.0%, p = 0.18) referrals, respectively. CONCLUSION: HEART-score modifications including the physicians' 'sense of alarm' may be used as a risk stratification tool for chest pain in primary care in the absence of routine access to troponin assays. Further validation is warranted.
Entities:
Keywords:
Chest pain; HEART score; Major adverse cardiac events; Primary care
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