• Dustin G Mark, Jie Huang, Chris J Kennedy, David R Vinson, Dustin W Ballard, Mary E Reed, and Kaiser Permanente CREST Network Investigators.
• Department of Emergency Medicine, Kaiser Permanente, 3600 Broadway, Oakland, CA 94611, USA; Department of Critical Care Medicine, Kaiser Permanente, 3600 Broadway, Oakland 94611, CA, USA; Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA. Electronic address: Dustin.G.Mark@kp.org.
• Am J Emerg Med. 2020 Dec 1; 38 (12): 2760.e5-2760.e8.

BackgroundA low (0-3) History, Electrocardiogram, Age, Risk factors and Troponin (HEART) score reliably identifies ED chest pain patients who are low risk for near-term major adverse cardiac events (MACE). To optimize sensitivity, many clinicians employ a modified HEART score by repeating troponin measurements and excluding patients with abnormal troponin values or ischemic electrocardiograms (ECGs). The residual MACE risk among patients with otherwise non-low (≥4) modified HEART scores is thus likely much lower than with non-low original HEART scores.ObjectiveTo explore residual 60-day MACE risks among patients with non-low modified HEART scores.MethodsSecondary analysis of a retrospective cohort of ED patients presenting with chest pain to an integrated healthcare system between 2013 and 2015. Patients with serial troponin measurements within 6 h of ED arrival were considered for inclusion. Exclusions included an ischemic ECG, troponin values above the 99th percentile or a lack of continuous health plan coverage through the 60-day follow-up period. MACE was defined as a composite of myocardial infarction, cardiac arrest, cardiogenic shock or death.ResultsThere were 22,976 study eligible patients encounters, 13,521 (59%) of which had non-low (≥4) modified HEART scores. The observed 60-day MACE risk among non-low HEART score patients was 2.0% (95% CI 1.8-2.3). When including all coronary revascularizations (MACE-R), the risk was 4.4% (95% CI 4.1-4.4).ConclusionRisk of near-term MACE among patients with non-low modified HEART scores (excluding those with abnormal troponin or ischemic ECGs) appears to be much lower than in the original HEART score validation studies.Copyright © 2020 Elsevier Inc. All rights reserved.

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