Assessing the Utility of the HEART Score in the Era of High-Sensitivity Troponin

There is uncertainty in the clinical utility of the HEART score, given its incorporation of an older generation of troponin assay. We sought to determine whether high-sensitivity troponin I (Hs-TnI) alone can effectively stratify cardiovascular risk in patients presenting to the emergency department (ED) with moderate or high HEART score by analyzing the management and outcomes of adults presenting to our ED with chest pain, moderate or high HEART score, and Hs-TnI below the 99th percentile. For this population, we calculated the negative predictive value (NPV) of Hs-TnI in ruling out a major adverse cardiac event (MACE; defined as myocardial infarction or death from a cardiovascular or unknown cause) at 30 days. Of 1331 patients included, 374 were admitted. Admitted patients underwent more stress tests (44.4% vs. 1.1%; p < 0.01) and diagnostic catheterizations (14.9% vs. 0.0%; p < 0.01). CT angiography was higher in those discharged (19.1% vs. 24.4%; p = 0.05). Patients admitted were more frequently discharged with new antiplatelets, statins, and anti-anginals (16.0% vs. 0.3%, 15.7% vs. 0.8%, and 15.7% vs. 1.2%; p < 0.01 for all comparisons). The overall incidence of 30-day MACE was 0.2%. Hs-TnI below the 99th percentile had an NPV of 99.8% in ruling out MACE at 30 days. In summary, in this cohort Hs-TnI alone had a high NPV in ruling out MACE at 30 days. Admitted patients had more intense management despite a similar event rate compared to those discharged, questioning the use of an elevated HEART score as the sole determinant of admission.