CALC Corner: HEART Score vs. EDACS

Chest pain is one of the most common chief complaints of patients presenting to the emergency department. While management of patients with clear ST-elevation MI is obvious, there remains some variation in the evaluation and management of undifferentiated chest pain patients in the emergency department.

By improving on the identification of low risk chest pain, physicians can avoid unnecessary tests and hospitalization for patients. The HEART Score has become the dominant chest pain risk stratification score used in the United States. Recent literature suggests EDACS may be another (or even better) alternative.

The Good (Why Use Them)

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• Both scores safely identify large numbers of chest pain patients who can be safely discharged (better resource utilization and shorter stays for low risk patients).
• Identify patients at low risk of Major Adverse Cardiac Event or MACE (all-cause mortality, myocardial infarction, coronary revascularization) within the following six weeks.
• Both scores were developed in the ED for use in the ED.

The Bad (Limitations)

• The HEART Score was originally derived and validated outside of the United States, but has since been implemented and studied prospectively in the US.
• EDACS was derived and validated in the same two centers, though they did use different cohort of patients, with subsequent validation in the US population.

The Ugly (Misapplication)

• Letting either score overrule your clinical gestalt — if a patient’s presentation concerns you, don’t let a CDR replace your judgment.
• Designed to risk stratify patients with undifferentiated chest pain — not those already diagnosed with Acute Coronary Syndrome (ACS).
• Of course, neither score should be used in patients with ST elevations on EKG or who are clinically unstable.

HEART (History, EKG, Age, Risk factors and Troponin) Score

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Derivation

• Single center in the Netherlands, 122 patients, retrospective observational study, 32% were low risk and 2.5% of low risk patients had MACE (96.6% sensitivity, 41.8% specificity)

Validation

• Four centers in New Zealand, 880 patients, retrospective observational study, 34% were low risk and 0.99% of low risk patients had MACE (98.1% sensitivity, 41.6% specificity)
• Ten centers in the Netherlands, 2,440 patients, prospective study, 36% were low risk and 1.7% of low risk patients had MACE (96.3% sensitivity, 43.2% specificity)

EDACS (Emergency Department Assessment of Chest pain Score)

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Derivation

• Two urban centers in Australia and New Zealand, 1,974 patients, prospective study, 42% low risk and 0.36% of low risk patients had MACE (99.0% sensitivity, 49.9% specificity)

Validation

• Two urban centers in Australia and New Zealand, 608 patients, prospective study, 51% low risk and 0% of low risk patients had MACE (100% sensitivity, 59% specificity)

Bottom Line

• Both scores are helpful in identifying low risk chest pain patients for early discharge.
• EDACS identified more low risk patients than HEART, but HEART currently has more robust external validation.

References:

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1. Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008; 16(6):191-196.
2. Backus BE, Six AJ, Kelder JC, Mast TP, van den Akker F, Mast EG, Monnink SH, van Tooren RM, Doevendans PAFM. Chest pain in the emergency room: a multicenter validation of the HEART score. Crit Pathw Cardiol. 2010; 9(3):164-169.
3. Backus BE, Six AJ, Kelder JC, Bosschaert MAR, Mast EG, Mosterd A, Veldkamp RF, Wardeh AJ, Tio R, Braam R, Monnink SHJ, van Tooren R, Mast TP, vand den Akker F, Cramer MJM, Poldervaart JM, Hoes AW, Doevendans PA. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013; 168(3):2153-2158.
4. Than M, Flaws D, Sander S, Doust J, Glasziou P, Kline J, Aldous S, Troughton R, Reid C, Parsonage WA, Framptom C, Greensalde JH, Deely JM, Hess E, Sadiq AB, Singleton R, Shopland R, Vercoe L, Woolhouse-Willams M, Ardagh M, Bossuyt P, Bannister L, Cullen L. Development and validation of the Emergency Department Assessment of Chest pain Score and 2 h accelerated diagnostic protocol. Emerg Med Australas. 2014; 26(1):34-44.
5. Mark DG, Huang J, Chettipally U, Kene MV, Anderson ML, Hess EP, Ballard DW, Vinson DR, Reed ME; Kaiser Permanente CREST Network Investigators. Performance of Coronary Risk Scores Among Patients With Chest Pain in the Emergency Department. J Am Coll Cardiol. 2018 Feb 13;71(6):606-616. doi: 10.1016/j.jacc.2017.11.064.