Emergency Department, Aberdeen Royal Infirmary, Aberdeen, UK
School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK.
Emerg Med J. 2023 Jul;40(7):474-481. doi: 10.1136/emermed-2022-213003. Epub 2023 Jun 2.
The History, Electrocardiogram (ECG), Age, Risk Factors and Troponin (HEART) score is commonly used to risk stratify patients with possible myocardial infarction as low risk or high risk in the Emergency Department (ED). Whether the HEART score can be used by paramedics to guide care were high-sensitivity cardiac troponin testing available in a prehospital setting is uncertain.
In a prespecified secondary analysis of a prospective cohort study where paramedics enrolled patients with suspected myocardial infarction, a paramedic Heart, ECG, Age, Risk Factors (HEAR) score was recorded contemporaneously, and a prehospital blood sample was obtained for subsequent cardiac troponin testing. HEART and modified HEART scores were derived using laboratory contemporary and high-sensitivity cardiac troponin I assays. HEART and modified HEART scores of ≤3 and ≥7 were applied to define low-risk and high-risk patients, and performance was evaluated for an outcome of major adverse cardiac events (MACEs) at 30 days.
Between November 2014 and April 2018, 1054 patients were recruited, of whom 960 (mean 64 (SD 15) years, 42% women) were eligible for analysis and 255 (26%) experienced a MACE at 30 days. A HEART score of ≤3 identified 279 (29%) as low risk with a negative predictive value of 93.5% (95% CI 90.0% to 95.9%) for the contemporary assay and 91.4% (95% CI 87.5% to 94.2%) for the high-sensitivity assay. A modified HEART score of ≤3 using the limit of detection of the high-sensitivity assay identified 194 (20%) patients as low risk with a negative predictive value of 95.9% (95% CI 92.1% to 97.9%). A HEART score of ≥7 using either assay gave a lower positive predictive value than using the upper reference limit of either cardiac troponin assay alone.
A HEART score derived by paramedics in the prehospital setting, even when modified to harness the precision of a high-sensitivity assay, does not allow safe rule-out of myocardial infarction or enhanced rule-in compared with cardiac troponin testing alone.
HEART 评分常用于急诊科（ED）对疑似心肌梗死患者进行低危或高危分层，该评分结合了病史、心电图（ECG）、年龄、危险因素和肌钙蛋白。但在院前环境中使用高敏肌钙蛋白检测时，急救人员能否使用 HEART 评分来指导治疗尚不确定。
这是一项前瞻性队列研究的预设二次分析，研究中急救人员对疑似心肌梗死患者进行入组，同时记录急救人员的心脏、心电图、年龄、危险因素（HEAR）评分，并采集院前血样进行后续的肌钙蛋白检测。使用实验室当前和高敏肌钙蛋白 I 检测方法得出 HEART 评分和改良 HEART 评分。将 HEART 和改良 HEART 评分≤3 和≥7 用于定义低危和高危患者，并评估 30 天内主要不良心脏事件（MACEs）的结局。
2014 年 11 月至 2018 年 4 月期间共招募了 1054 名患者，其中 960 名（平均 64（15）岁，42%为女性）符合分析条件，255 名（26%）在 30 天内发生 MACE。HEART 评分≤3 分可识别 279 名（29%）低危患者，当前检测法的阴性预测值为 93.5%（95%CI 90.0%至 95.9%），高敏检测法的阴性预测值为 91.4%（95%CI 87.5%至 94.2%）。使用高敏检测法的检测限对改良 HEART 评分≤3 分，可识别 194 名（20%）低危患者，阴性预测值为 95.9%（95%CI 92.1%至 97.9%）。与单独使用任何一种肌钙蛋白检测法的检测上限相比，使用任何一种检测法的 HEART 评分≥7 分的阳性预测值都较低。
在院前环境中由急救人员得出的 HEART 评分，即使经过改良以利用高敏检测法的精确性，也不能与单独使用肌钙蛋白检测相比，安全地排除或增强对心肌梗死的诊断。
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