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My hope that this is a powerful tool to help assess and send home low-risk chest pain. I’ve taken care of a lot of chest pain cases, whether in the emergency room, telemetry unit or ICU, which means I’ve been burned by chest pain. I want to give you’re a mnemonic that will help you assess chest pain, but also protect yourself and legally defend your charts. It’s called the HEART Score and it’s fantastic.
- Risk factors
Each one of these factors will give you zero, one or two points.
If the history is highly suspicious, it gets two points; mildly suspicious means one point and non-suspicious gets zero points.
Looking at JAMA’s content, radiation is sinister, especially radiation to the right arm or both arms. If associated with exertion, it’s considered sinister as well. The likelihood ratio is pretty high for patients who have diaphoresis or nausea and vomiting. The mnemonic I teach for going over the history is DRIVE because I want to drive home the importance of the history so we don’t get burned.
- I won’t get burned – a filler letter
Is it significant segment depression? Is it nonspecific repolarization? Is it normal? You have to know how to read EKGs if you’re taking care of chest pain. We have a black belt EKG curriculum that I’m really proud of, as I taught EKG interpretation for years at colleges and national conferences. This is a great place to start getting familiar with EKGs.
Greater than 64 gets two points, 46 to 64 is one point, less than 46 means no points.
If they have more than two risk factors, you get two points. Also in the JAMA, there was a study of over half a million patients between 1994 and 2006. They presented with their first MI and 86% had one of the major risk factors, which you can remember using the mnemonic SADCHF.
- Family history
Look at these risk factors and weigh them with the HEART Score. Those are arterial risk factors.
Diabetes as a Risk Factor
I got an email right after one of my conferences last year, where I talked about how risky diabetic patients are. The email said, “I have a sad story for you. One of our patients, a 52-year-old diabetic male, went to the ER and said he had a toothache. He was given antibiotics and sent home. Returned to the ER in cardiac arrest and died. You’re right.”
I feel for that ER provider because I may have done the same thing.
If troponins are two times normal, you get two points. If they’re elevated, you get one point, or if they’re normal or low, you get zero points. I don’t care if it’s mildly positive, it’s still positive. They will not go home with elevated troponins when I’m in the emergency room.
Interpreting HEART Score
With a score of zero to three, the patient has a 1.7% risk of a major adverse coronary event. If the score is intermediate, four to six points, they are at a 16% risk of something bad happening. A high-risk score of seven to 10 equals a 50% chance. That’s when you want to get an intervention cardiologist.
The HEART Score is used for low-risk chest pain. But still, 1.7% means that out of every 50 chest pain patients I send home, one of them is going to have something bad happen. Is that acceptable? I don’t know.
They found that 1.7% of patients with a score of zero to three had a major adverse cardiac event within six weeks. But here’s the deal: if we hold the patient and check troponin three hours later, the risk of something bad happening decreases to less than 1%. This makes me very confident to send them home and document that I’m within a standard of care, as I applied the HEART Score.
My hope is that this gets you thinking about how you use the HEART Score. If you’re an advanced practitioner and you’re sending home chest pain, that’s risky. You should be consulting with your supervising doc. Make sure your attending doc is on board with your decision making. Explain your decision making to the patient and make sure they’re on board.
This is a situation where you don’t want your IE (intelligence to ego) ratio to get out of control. Chest pain is risky and you have to know what you’re doing. Don’t make your ego higher than your intelligence. Make sure you know what you’re doing. That takes seeing lots and lots of chest pain patients in concert with a supervising physician or another supervisor.