Impact of use of the HEART score in chest pain patients. Judith Poldervaart, MD, PhD Julius Center
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1 Impact of use of the HEART score in chest pain patients Judith Poldervaart, MD, PhD Julius Center
2 The HEART-score Diagnostic risk score for chest pain patients at ED 5 clinical elements Supports direct clinical decision Risk category HEART score Policy Low 0-3 Discharge Intermed 4-6 Observation High 7-10 Invasive
3
4 HEART-Impact trial: hypothesis Fast & accurate risk stratification with HEART score Improves management & care in chest pain patients Fewer admissions and diagnostic procedures in low-risk More aggressive in high-risk However, without increasing incidence of cardiac events! non-inferiority design Theory practice??
5 Methods Location of inclusion 9 Dutch hospitals July 2013 August 2014 Inclusion Chest pain Able to give informed consent Primary outcome MACE within 6 weeks unstable angina NSTEMI STEMI CAG conservatively PCI CABG Death Adjudication committee Exclusion STEMIs Secondary outcomes Use of health care resources Recurrent ED visit (Re)admission Out-patient clinic visit GP visit Diagnostic procedures Quality of life Direct costs Indirect costs Cost-effectiveness
6 Methods: study protocol
7 HEART-Impact trial: stepped wedge
8 Results: patient flow
9 Results: baseline characteristics All patients Usual care HEART care (N=3,648) (N=1,827) (N=1,821) Demographics # male 1980 (54%) 1005 (55%) 975 (54%) Mean age (SD) 62 (14) 62 (14) 62 (14) History of cardiovascular disease 1266 (35%) 670 (37%) 596 (33%) HEART score HEART score 0-3 (low risk) (40%) HEART score 4-6 (intermediate risk) (49%) HEART score 7-10 (high risk) (11%)
10 Results: incidence of MACE Usual care HEART care HEART 0-3 HEART 4-6 HEART 7-10 (n=1,827) (n=1,821) (n=715) (n=861) (n=190) Number of patients with MACE 405 (22.2%) 345 (18.9%) 14 (2.0%) 175 (20.2%) 140 (73.7%) MACE - components* Death total 9 (0.5%) 5 (0.3%) 1 (0.1%) 2 (0.2%) 2 (1.1%) Cardiovascular death Non-cardiovascular death Death by unknown cause Cardiac ischemia total 400 (21.9%) 329 (18.1%) 10 (1.4%) 162 (18.8%) 143 (75.3%) Unstable angina NSTEMI STEMI Significant stenosis total 290 (15.9%) 247 (13.6%) 10 (1.4%) 117 (13.6%) 102 (11.8%) Stenosis managed conservatively PCI CABG Total number of MACE * total of MACE components exceeds MACE total: 1 patient can have > 1 component
11 Results: non-inferiority Non-inferiority margin: absolute risk difference in MACE usual care & HEART care 95% one-sided CI of should not exceed margin of 3%
12 Results: non-inferiority of HEART care
13 Results: initial presentation at ED Usual care HEART care HEART score 0-3 HEART score 4-6 HEART score 7-10 HEART unknown INFORMATION AVAILABLE IN ALL NINE HOSPITALS n=1,827 n=1,821 n=715 n=861 n=190 n=55 Initial presentation at ED (a) not admitted no. (%) 1,199 (66%) 1,263 (69%) 648 (91%) 556 (65%) 29 (15%) 30 (55%) Of which prompt discharge < 4h* 564 (47%) 633 (50%) 416 (64%) 190 (34%) 9 (31%) 18 (60%) Of which prolonged observation at ED/CPU 635 (53%) 630 (50%) 232 (36%) 366 (66%) 20 (69%) 12 (40%) Median length of stay at ED in hours:min (P25-P75) 3:57 (2:30-5:57) 3:55 (2:35-5:44) 3:16 (2:21-4:43) 4:40 (2:56-6:20) 3:32 (2:16-5:51) 2:57 (2:17-5:11) (b) hospital admission no. (%) 628 (34%) 558 (31%) 67 (9%) 305 (35%) 161 (85%) 25 (45%) Of which admission to CCU/ICU after ED 296 (47%) 223 (40%) 25 (37%) 104 (34%) 81 (50%) 13 (50%) Median duration of stay in days (P25-P75) 4 (2-6) 3 (2-6) 2 (2-3) 3 (2-5) 4 (3-8) 4 (2-7) Total number of days Of which days on CCU / ICU recurrent visit at ED no. (%) 266 (15%) 277 (15%) 72 (10%) 151 (18%) 46 (24%) 8 (15%) Total number of visits Final diagnosis cardiac ischemia readmission, non-elective no. (%) 221 (12%) 193 (11%) 49 (10%) 104 (12%) 37 (19% 3 (5%) Total number of readmissions Median number of days (P25-P75) 2 (0-6) 2 (0-6) 2 (0-4) 2 (0-7) 2 (0-7) 2 (0-4) 1 out-patient clinic visit no. (%) 1,093 (60%) 1,267 (70%) 381 (53%) 686 (80%) 165 (87%) 35 (64%) Total number of visits Specialism cardiology Specialism other than cardiology new visit at GP for cardiac reason no. (%) 195 (11%) 213 (12%) 86 (12%) 102 (12%) 18 (9%) 7 (13%)
14 Results: recurrent ED visits, readmissions, out-patient clinic visits, GP visits No difference after adjustment for clustering and time
15 Results: diagnostic procedures Usual care N=1,176 HEART care N=804 HEART 0-3 N=346 HEART 4-6 N=361 HEART 7-10 N=65 HEART unknown N=32 Number of patients with one or more of the tests mentioned in this table 765 (65%) 461 (57%) 137 (40%) 250 (69%) 56 (86%) 18 (56%) Diagnostic testing total numbers 1, Number of tests within first two days 582 (37%) 347 (37%) 49 (21%) 216 (40%) 65 (48%) 17 (49%) Stress bicycle ECG testing 465 (40%) 300 (37%) 96 (28%) 175 (48%) 18 (28%) 11 (34%) Echocardiography (transthoracic) 410 (35%) 243 (30%) 50 (15%) 142 (39%) 43 (66%) 8 (25%) Nuclear imaging 198 (17%) 89 (11%) 24 (7%) 56 (16%) 8 (12%) 1 (0%) CT-scan or CT-angiography (excluding PE) 87 (7%) 47 (6%) 16 (5%) 27 (7%) 3 (5%) 1 (0%) Coronary CT-Angiography (CCTA) 40 (3%) 26 (3%) 14 (4%) 10 (3%) 0 (0%) 2 (1%) Cardiac MRI 19 (2%) 16 (2%) 6 (2%) 10 (3%) 0 (0%) 0 (0%) Coronary angiography (CAG) 346 (29%) 219 (27%) 22 (6%) 121 (34%) 64 (98%) 12 (38%) CAG: normal coronary arteries CAG: non-significant stenosis CAG: significant stenosis conservatively treated CAG: significant stenosis invasively treated
16 Results: non-adherence to recommended HEART policy No discharge in low-risk patients No additional testing in high-risk patients Usual care HEART care HEART low-risk HEART high-risk N=1,827 N=1,766 N=715 N=190 Adherence to HEART policy* Yes No Yes No Yes No n/a N=1,453 N= (82.3%) (17.7%) (59.3%) (40.7%) (88%) (12%) MACE within 6 weeks (22.2%) (21.7%) (4.5%) (0.7%) (3.8%) (82%) (14%) MACE only AMI, emergency revascularisation and death (13.3%) (14.0%) (1.6%) (0%) (1.7%) (67%) (0%) Discharge 4 hours after presentation (47%) (37.8%) (21.1%) (84.7%) (19.6%) (0%) (40%) Prolonged observation at ED (53%) (30.1%) (57.5%) (15.3%) (57.4%) (4%) (59%) Initial admission to hospital (34%) (32.1%) (21.4%) (0%) (23.7%) (100%) (0%) Recurrent ED visits within 3 months (15%) (16.0%) (11.5%) (9.7%) (10.7%) (24%) (23%) Non-elective readmissions within 3 months (12%) (11.3%) (8.3%) (6.1%) (8.2%) (21%) (9%) Outpatient clinic visits within 3 1,093 1, months (60%) (70.5%) (66.1%) (44.1%) (64.9%) (86%) (82%)
17 What do our results mean? HEART score is safe No increase of MACE during HEART care Low risk MACE incidence: 2.0% (including UA and elective PCI) Only limited impact on management After adjustment for clustering and time steps, no difference in early discharge <4 hours, readmissions, recurrent ED visits, outpatient clinic visits, GP visits or diagnostic procedures occurred 232 low-risk patients: prolonged observation at ED/CPU Non-adherence
18 Clinical implications Use of HEART score safe in work-up chest pain patients Identification of barriers for acceptance and use Chest pain remains diagnostic dilemma: What is an acceptable risk?
19 Patients Acknowledgements Residents Participating hospitals Pieter Doevendans, UMC Utrecht Clara van Ofwegen, Diakonessenhuis, Utrecht Jacob Six, Hofpoort, Woerden Thomas Oosterhof, Gelderse vallei Ede Jan-Melle van Dantzig, Catharina, Eindhoven Herman Mannaerts, Amstelland, Amstelveen Yolande Appelman, Vumc, Amsterdam Benno Rensing, St. Antonius, Nieuwegein Nicolette Ernst, Atrium, Heerlen Investigator team Arno Hoes Pieter Doevendans Hans Reitsma Jacob Six Barbra Backus Erik Koffijberg Judith Poldervaart
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