A 50 year old male presents with transient chest pain that is described as “crushing” that occurred while mowing his lawn, one hour prior to arrival. He has no significant health history and takes no medications.
So one, or two troponins? If negative EKG and troponin, see you later…
We are admitting millions of patients with low risk chest pain at a cost to the hospital system, of greater than 10 billion dollars per year [1, 2]. Why not just admit? It is a large area of controversy and highest pay out when we talk about emergency medicine litigation and most importantly…people die!
Why should I assume the liability and care of future healthcare costs? They came for my medical opinion and I provided it.
Let us be practical. Admission for low risk chest pain is unsustainable, and as patients are shifted to HMO and ACO care and payment models, there will be mandates to reduce such low-value care. Thus, it will become vital for our survival in this specialty, to determine whom a more reasonable approach is safe!
The HEART score has shown promise as a decision instrument tool with much more utility than the TIMI or GRACE score. What is the HEART score? If you have not heard of it on EMRAP, ERCAST, or REBEL CAST you must not be a FOAMed enthusiast or spend a majority of your time under a rock. Maybe you read something in EP monthly. If not, it uses 5 criteria:
Risk factors were defined as diabetes, current or recent (30). Significant ST depression were defined as changes of 1mm or greater. T wave inversions and ST depression of 0.5mm were considered non-specific.
2440 patients that presented with chest pain were enrolled and evaluated for a major adverse cardiac event (MACE) within 6 weeks (AMI, positive catheterization, PCI, CABG, or death). The overall population demonstrated that 17% had a MACE within 6 weeks, 6.4% had an AMI, and 0.7% died .
- Score 0-3:
- 1.7% had a MACE
- 0.4% (1 patient) died
- 36.4% of patients were in this low risk group
- Score 4-6:
- 16.6% had a MACE Score
- Score 7-10:
- 50.1% had a MACE
Furthermore, Wake Forest has adopted the Heart score across their system. In their studies, they utilized 2 troponins (at arrival and 3 hours later) rather than the originally proposed single troponin, and have found that they decreased their miss rate from 1.7% to less than 1% at 30 days with no deaths . Most importantly, none of the patients identified for early discharge, had any major adverse cardiac events within 30 days.
Weinstock’s et al JAMA 2015 study sought to determine the incidence of clinically relevant adverse cardiac events in patients hospitalized for chest pain with two negative troponins, in non-concerning initial ED vital signs, and non-ischemic and interpretable EKG. The primary outcome was a composite of life-threatening arrhythmias, inpatient ST elevation MI, cardiac or respiratory arrest, or death during hospitalization. Prior to excluding patients with abnormal vital signs, the primary end point occurred in 20 of the 11,230 patients. The conclusion is adult patients with chest pain admitted with two negative troponins, non-ischemic EKG, non-concerning vital signs, and short term clinically relevant adverse cardiac events (CRACE) were rare and commonly iatrogenic, suggesting routine inpatient admission may not be a beneficial strategy in this group. My only concern with this study was that the repeat cardiac markers were 3-7 hours from arrival . I certainly do not want to keep someone in my department for 7 hours!
In addition to the use of the HEART score, a Shared Medical Decision-Making Model has been investigated for incorporation into the guideline. Such a tool has been demonstrated to increase patient knowledge, communication, and a feeling of engagement in decision-making. 
It is also important to note the AHA Guidelines recommend patients still have follow-up for additional diagnostics or management as indicated. Patients at low-risk and with negative biomarkers are at profoundly low-risk for events in, at least, the very short term.
None of this data is strong enough to claim that there is no risk. The risk is minimal, with thousands of patients requiring hospitalization to obtain benefit for one patient. However, that benefit is not preventing MACE (major adverse cardiac events) but rather patients who would be dead if not observed in the hospital. This strategy isn’t zero miss.
As physicians, we are advocates for our patients and we want to make sure we guide them to receive appropriate and safe medical care. Admitting thousands of patients to the hospital entails risk such as falls, medication errors, hospital acquired infections, and false positive testing leading to unnecessary additional testing and procedures. According to Makary, et al. BMJ May 2016, hospitalization is the 3rd leading cause of death . Furthermore, a study by James, JT. J Patient Saf. 2013 found that patients admitted to the hospital had an incidence of iatrogenic death of 1 in 160 .
Does shared decision making decrease our exposure to liability? No one really knows at this time. However, as we continue to be the specialty that advocates for our patients, the question is whether to continue to spend billions of dollars for work ups that may be continued in an outpatient setting, or discuss what may be a safe alternative. Would I recommend this for my loved one? Absolutely. Assuming, of course, that my loved one is able to assure follow up and understands when to return. This is why the court is in favor of the defendant greater than 75% of the time, because we care!
I obviously do not completely agree with entire HEART score. However, it does permit me the ability to stratify my “low risk” chest pain patients and discuss going home.
Hijinio Carreon DO
Special thanks to Dr. Amal Mattu for his contribution on this Blog post and Dr. Backus for her HEART Score cards!
1. Levit K, Stranges E, Ryan K, Elixhauser A. Exhibit 2.1: most frequent principal diagnoses. In: HCUP Facts and Figures, 2006: Statistics on Hospital-Based Care in the United States. Rockville, MD: Agency for Healthcare Research and Quality; 2008:19. http://www.hcup-us.ahrq.gov/reports/factsandfigures/HAR_2006.pdf. Accessed April 7, 2015.
2. Levit K, Stranges E, Ryan K, Elixhauser A. Inpatient Hospital Stays for Principal Diagnosis*: Average Length of Stay and Average Charges, 2006. HCUP Facts and Figures, 2006: Statistics on Hospital-Based Care in the United States. Rockville, MD: Agency for Healthcare Research and Quality; 2008. http://www.hcup-us.ahrq.gov/reports/factsandfigures/figures/2006/2006_4_3.jsp. Accessed April 7, 2015.
3. James, JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013 Sep;9(3):122-8.
4. Backus, et. al., A prospective validation of the HEART score for chest pain patients at the emergency department. International Journal of Cardiology 168 (2013) 2153-2158.
5. Mahler, et al., A prospective validation of the HEART score for chest pain patients at the emergency department wake forest. Circ Cardiovasc Qual Outcomes. 2015;8:00-00. DOI: 10.1161/CIRCOUTCOMES.114.001384
6. Hess, et al. The Chest Pain Chose Decision Aid: A Randomized Trial. Circ Cardiovasc Qual Outcomes. 2012:5: 251-259
7. Weinstock, MB et al. Risk for clinically relevant adverse cardiac events in patients with chest pain at hospital admission. JAMA Intern Med. 2015 ;175(7):1207-1212
8. Makary, et al. Medical error—the third leading cause of death in the US BMJ 2016; 353 doi: http://dx.doi.org/10.1136/bmj.i2139 (Published 03 May 2016)