Emergency Department, North Bristol NHS Trust, Bristol, UK
Emergency Department, Southmead Hospital, Bristol, UK.
Emerg Med J. 2022 Jul;39(7):515-518. doi: 10.1136/emermed-2021-211669. Epub 2021 Nov 9.
Patients presenting to EDs with chest pain of possible cardiac origin represent a substantial and challenging cohort to risk stratify. Scores such as HE-MACS (History and Electrocardiogram-only Manchester Acute Coronary Syndromes decision aid) and HEAR (History, ECG, Age, Risk factors) have been developed to stratify risk without the need for troponin testing. Validation of these scores remains limited.
We performed a post hoc analysis of the Limit of Detection and ECG discharge strategy randomised-controlled trial dataset (n=629; June 2018 to March 2019; 8 UK hospitals) to calculate HEAR and HE-MACS scores. A <4% risk of major adverse cardiac events (MACE) at 30 days using HE-MACS and a score of <2 calculated using HEAR defined 'very low risk' patients suitable for discharge. The primary outcome of MACE at 30 days was used to assess diagnostic accuracy.
MACE within 30 days occurred in 42/629 (7%) of the cohort. HE-MACS and HEAR scores identified 85/629 and 181/629 patients as 'very low risk', with MACE occurring in 0/85 and 1/181 patients, respectively. The sensitivities of each score for ruling out MACE were 100% (95% CI: 91.6% to 100%) for HE-MACS and 97.6% (95% CI: 87.7% to 99.9%) for HEAR. Presenting symptoms within these scores were poorly predictive, with only diaphoresis reaching statistical significance (OR: 4.99 (2.33 to 10.67)). Conventional cardiovascular risk factors and clinician suspicion were related to the presence of MACE at 30 days.
HEAR and HE-MACS show potential as rule out tools for acute myocardial infarction without the need for troponin testing. However, prospective studies are required to further validate these scores.
因可能的心脏原因到急诊科就诊的胸痛患者是一个需要进行风险分层的重要且具有挑战性的人群。HE-MACS（仅基于病史和心电图的曼彻斯特急性冠状动脉综合征决策辅助工具）和 HEAR（病史、心电图、年龄、危险因素）等评分已被开发出来，用于在无需进行肌钙蛋白检测的情况下进行风险分层。这些评分的验证仍然有限。
我们对 Limit of Detection and ECG discharge strategy 随机对照试验数据集（n=629；2018 年 6 月至 2019 年 3 月；8 家英国医院）进行了事后分析，以计算 HEAR 和 HE-MACS 评分。使用 HE-MACS 计算的 30 天内主要不良心脏事件（MACE）风险<4%和使用 HEAR 计算的<2 分定义为“极低风险”患者适合出院。30 天内的 MACE 主要结局用于评估诊断准确性。
629 例患者中有 42 例（7%）在 30 天内发生 MACE。HE-MACS 和 HEAR 评分将 85/629 和 181/629 例患者归类为“极低风险”，其中 0/85 例和 1/181 例患者发生 MACE。两种评分对排除 MACE 的敏感度分别为 100%（95%CI：91.6%至 100%）和 97.6%（95%CI：87.7%至 99.9%）。这些评分中的表现症状预测价值较低，只有出汗达到统计学意义（OR：4.99（2.33 至 10.67））。传统心血管危险因素和临床医生的怀疑与 30 天内 MACE 的发生有关。
HEAR 和 HE-MACS 有可能成为无需肌钙蛋白检测即可排除急性心肌梗死的工具。然而，需要前瞻性研究来进一步验证这些评分。
