Effect of Using the HEART Score in Patients With Chest Pain in the Emergency Department: A Stepped-Wedge, Cluster Randomized Trial
Publication date
2017-05-16
Authors
Poldervaart, J.M.
Reitsma, Johannes J B
Backus, B.E.
Koffijberg, Hendrik
Veldkamp, Rolf F
Ten Haaf, Monique E
Appelman, Yolande
Mannaerts, Herman F J
van Dantzig, Jan-Melle
van den Heuvel, Madelon
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Supervisors
Document Type
Article
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taverne
Abstract
Background: The 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. Objective: To measure the effect of use of the HEART score on patient outcomes and use of health care resources. Design: Stepped-wedge, cluster randomized trial. (Clinical Trials.gov: NCT01756846) Setting: Emergency departments in 9 Dutch hospitals. Patients: Unselected patients with chest pain presenting at emergency departments in 2013 and 2014. Intervention: All 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. Measurements: For 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. Results: A 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. Limitation: Physicians were hesitant to refrain from admission and diagnostic tests in patients classified as low risk by the HEART score. Conclusion: Using 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.
Keywords
Taverne, Internal Medicine, Randomized Controlled Trial, Journal Article
Citation
Poldervaart, J M, Reitsma, J B, Backus, B E, Koffijberg, H, Veldkamp, R F, Ten Haaf, M E, Appelman, Y, Mannaerts, H F J, van Dantzig, J-M, van den Heuvel, M, El Farissi, M, Rensing, B J W M, Ernst, N M S K J, Dekker, I M C, den Hartog, F R, Oosterhof, T, Lagerweij, G R, Buijs, E M, van Hessen, M W J, Landman, M A J, van Kimmenade, R R J, Cozijnsen, L, Bucx, J J J, van Ofwegen-Hanekamp, C E E, Cramer, MJ, Six, A J, Doevendans, P A & Hoes, A W 2017, 'Effect of Using the HEART Score in Patients With Chest Pain in the Emergency Department : A Stepped-Wedge, Cluster Randomized Trial', Annals of Internal Medicine, vol. 166, no. 10, pp. 689-697. https://doi.org/10.7326/M16-1600