HEART score and clinical gestalt do just as well diagnosing ACS

By Will Boggs MD

NEW YORK (Reuters Health) - The diagnostic accuracies of the HEART score and clinical gestalt are similar for diagnosing acute coronary syndrome (ACS) in patients presenting to the emergency department (ED) with chest pain, researchers from the Netherlands report.

"Our study is not a call to abandon HEART score, since it is the best risk stratification tool for chest pain patients in the ED currently available," Dr. Ewoud ter Avest from Medical Center Leeuwarden told Reuters Health by email. "However, since its diagnostic accuracy does not exceed clinical gestalt, it is probably wise not to rely on formal risk stratification instruments only, but to combine these with gestalt in order to get the best of two worlds when evaluating chest pain patients in the ED."

The HEART score contains history, ECG, age, risk factors, and troponins, each of which can be scored between 0 and 2, for a maximum score of 10. The score accurately predicts the risk of the composite of acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft surgery, and death within the next six weeks.

Dr. ter Avest's team set out to compare the accuracy of the HEART score with that of clinical gestalt for diagnosing ACS in an unselected population of patients with chest pain presenting to the ED.

Of the 255 patients included in the study, a third had a low HEART score (0-3), 44% had an intermediate HEART score (4-6), and 22% had a high HEART score. By comparison, clinical gestalt ranked the risk of ACS as low in 31%, intermediate in 38%, and high in 31% of patients.

Seventy-five patients (29%) had an ACS, including 67 who fulfilled the criteria for acute myocardial infarction, the researchers report in Emergency Medicine Journal, online September 12.

The prevalence of ACS increased with increasing HEART score and with increasing clinical gestalt-based risk, but ACS also occurred in five patients with low HEART scores and 10 patients deemed at low risk by clinical gestalt.

The overall diagnostic agreement between HEART score and clinical gestalt was low. "Low" HEART scores were more sensitive and had a lower negative likelihood ratio for ACS than did a "low-risk" gestalt-based ranking. Similarly, "high" HEART scores were more specific and had a higher positive likelihood ratio for ACS than "high-risk" gestalt rankings did.

In receiver operating curve comparisons, though, there was no significant difference in overall diagnostic performance between HEART score and clinical gestalt.

"This comes as no surprise, since many HEART score elements are also used (consciously or subconsciously) to determine clinical gestalt based risk of ACS," Dr. ter Avest said. "Risk assessment based on clinical gestalt offers the opportunity to weigh the risk factors that are included in the HEART score differently. It has an additional advantage, since factors not included in the HEART score can be taken into account as well. However, the disadvantage of gestalt is that it is not 'structured,' and thereby more dependent on the individual doctor's judgment capabilities."

SOURCE: http://bit.ly/1roxkOr

Emerg Med J 2014.

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