• Judith M Poldervaart, Johannes B Reitsma, Barbra E Backus, Hendrik Koffijberg, Rolf F Veldkamp, Monique E Ten Haaf, Yolande Appelman, MannaertsHerman F JHFJFrom University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hos, Jan-Melle van Dantzig, Madelon van den Heuvel, Mohamed El Farissi, Bernard J W M Rensing, Nicolette M S K J Ernst, Ineke M C Dekker, Frank R den Hartog, Thomas Oosterhof, Ghizelda R Lagerweij, Eugene M Buijs, van HessenMaarten W JMWJFrom University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina H, LandmanMarcel A JMAJFrom University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospi, van KimmenadeRoland R JRRJFrom University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina, Luc Cozijnsen, Jeroen J J Bucx, Clara E E van Ofwegen-Hanekamp, Maarten-Jan Cramer, A Jacob Six, Pieter A Doevendans, and Arno W Hoes.
• From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen; Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
• Ann. Intern. Med. 2017 May 16; 166 (10): 689-697.

BackgroundThe HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score is an easy-to-apply instrument to stratify patients with chest pain according to their short-term risk for major adverse cardiac events (MACEs), but its effect on daily practice is unknown.ObjectiveTo measure the effect of use of the HEART score on patient outcomes and use of health care resources.DesignStepped-wedge, cluster randomized trial. (ClinicalTrials.gov: NCT01756846).SettingEmergency departments in 9 Dutch hospitals.PatientsUnselected patients with chest pain presenting at emergency departments in 2013 and 2014.InterventionAll hospitals started with usual care. Every 6 weeks, 1 hospital was randomly assigned to switch to "HEART care," during which physicians calculated the HEART score to guide patient management.MeasurementsFor safety, a noninferiority margin of a 3.0% absolute increase in MACEs within 6 weeks was set. Other outcomes included use of health care resources, quality of life, and cost-effectiveness.ResultsA total of 3648 patients were included (1827 receiving usual care and 1821 receiving HEART care). Six-week incidence of MACEs during HEART care was 1.3% lower than during usual care (upper limit of the 1-sided 95% CI, 2.1% [within the noninferiority margin of 3.0%]). In low-risk patients, incidence of MACEs was 2.0% (95% CI, 1.2% to 3.3%). No statistically significant differences in early discharge, readmissions, recurrent emergency department visits, outpatient visits, or visits to general practitioners were observed.LimitationPhysicians were hesitant to refrain from admission and diagnostic tests in patients classified as low risk by the HEART score.ConclusionUsing the HEART score during initial assessment of patients with chest pain is safe, but the effect on health care resources is limited, possibly due to nonadherence to management recommendations.Primary Funding SourceNetherlands Organisation for Health Research and Development.

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