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- Title
Effect of Using the HEART Score in Patients With Chest Pain in the Emergency Department: A Stepped-Wedge, Cluster Randomized Trial.
- Authors
Poldervaart, Judith M.; Reitsma, Johannes B.; Backus, Barbra E.; Koffijberg, Hendrik; Veldkamp, Rolf F.; ten Haaf, Monique E.; Appelman, Yolande; Mannaerts, Herman F. J.; van Dantzig, Jan-Melle; van den Heuvel, Madelon; el Farissi, Mohamed; Rensing, Bernard J. W. M.; Ernst, Nicolette M. S. K. J.; Dekker, Ineke M. C.; den Hartog, Frank R.; Oosterhof, Thomas; Lagerweij, Ghizelda R.; Buijs, Eugene M.; van Hessen, Maarten W. J.; Landman, Marcel A. J.
- Abstract
<bold>Background: </bold>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.<bold>Objective: </bold>To measure the effect of use of the HEART score on patient outcomes and use of health care resources.<bold>Design: </bold>Stepped-wedge, cluster randomized trial. (ClinicalTrials.gov: NCT01756846).<bold>Setting: </bold>Emergency departments in 9 Dutch hospitals.<bold>Patients: </bold>Unselected patients with chest pain presenting at emergency departments in 2013 and 2014.<bold>Intervention: </bold>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.<bold>Measurements: </bold>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.<bold>Results: </bold>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.<bold>Limitation: </bold>Physicians were hesitant to refrain from admission and diagnostic tests in patients classified as low risk by the HEART score.<bold>Conclusion: </bold>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.<bold>Primary Funding Source: </bold>Netherlands Organisation for Health Research and Development.
- Subjects
CHEST pain treatment; ELECTROCARDIOGRAPHY; TROPONIN; QUALITY of life; CLINICAL trials; PHYSIOLOGY; THERAPEUTICS; CORONARY disease; DIAGNOSIS; AGE distribution; CHEST pain; COMPARATIVE studies; COST effectiveness; HOSPITAL emergency services; LONGITUDINAL method; RESEARCH methodology; MEDICAL care costs; MEDICAL cooperation; MEDICAL history taking; RESEARCH; RISK assessment; EVALUATION research; RANDOMIZED controlled trials; ECONOMICS
- Publication
Annals of Internal Medicine, 2017, Vol 166, Issue 10, p689
- ISSN
0003-4819
- Publication type
journal article
- DOI
10.7326/M16-1600