May 31, 2022
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A Brief Guide to Clinical Decision Support System
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Top 5 Advantages of Clinical Decision Support System (CDS)
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Understanding HEART Score- A Detailed Guide
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What is A HEART Score and How It is Calculated
The EH Score... Because the HEART Score Is Rubbish
The HEART score should not be used to trump your own clinical decision making. It is not better than the gestalt of an emergency physician. I only document a HEART score if I discharge a chest pain patient and the HEART score happens to be 3 or less. I still discharge patients with HEART score >3. I just don’t document the HEART score. I also do not let heart score of 3 or less prevent me from pushing for an admission on a patient I am concerned about.
The HEART score does not factor into my clinical decision making. I check it as an afterthought to see if I can add beef to my documentation. I have a simpler score. It’s perfect since I am Canadian. But first, I’m going to criticize the components of this HEART score that has gained so much popularity in EM.
Why HEART is rubbish, letter by letter.
History: Why do you need to proceed if you think the history is “highly suspicious?” By this scoring system, you only get 2 points for a highly suspicious history, meaning you have a point to spare to still be considered low risk by HEART. This is ridiculous, and implies this scoring system is intended for complete novices in evaluating the chest pain patient. If you are giving 2 points for H, you are done – the patient is being admitted.
EKG: You get 2 points for “significant ST-depression.” Once again, this implies this scoring system is intended for complete novices. I will explain in detail later on, but not all ST depressions are created equal, and the dreaded horizontal (or planar) ST depression is a Do-Not-Pass-GO finding. In fact, people with this type of ST depression and ST elevations (i.e. STEMI) do better than people with this type of ST depression alone (i.e. NSTE-ACS with ischemic EKG). Meanwhile there are other ST depressions that are fairly benign.
Age: You get 2 points for being >65. I am less worried about missing an atypical presentation of ACS in someone >65 than someone <45 (0 points according to HEART). The patient who is 35-45 with chest pain, with a family that is still very much dependent on the patient being alive and well is much higher risk than the nursing home patient. The cases that end up in books like Bouncebacks are younger because they wind up being the ones with the multi-million dollar lawsuit.
Risk factors: The set list of risk factors includes sedentary lifestyle, smoking, HTN, HLP, smoking, and family history of early CAD. It really misses some of the riskier risk factors such as CKD, lupus, and antiphospholipid syndrome.
Troponin: It takes balls to discharge someone with chest pain and an elevated troponin. Balls you should not have or even be curious about acquiring.
The EH score!
There are two binary decisions. Is the EKG bad? Is the History bad? E and H. 0 or 1. If the score is 2, you start heparin, and you call intervention to try to get a cath as soon as possible. If the score is 1, you admit the patient, and call the cardiologist for recs and see if he/she wants anything started in the ED. If the score is 0, you call the cardiologist to see if expedited outpatient follow-up can be arranged.
EKG is the most important part of my chest pain evaluation. I like to see it before the patient. After I decide there is no concern for STEMI, I look for ST depressions.
A is ischemia. It is more specific for ischemia than ST elevations. If these depressions are in leads V1-3, posterior leads must be obtained to evaluate for posterior wall STEMI. Otherwise, this would get you 1 point for E.
B is ischemia vs LVH. It really depends on the T wave. If the ST downslopes into an inverted T wave in the lateral leads, this is LVH, which is not concerning, especially if it is present on an old EKG. This gets you 0 for E. If the ST downslopes into an upright T wave, this is concerning for ischemia, especially if it is not present on an old EKG. This gets you 1 point for E.
C is unlikely to be ischemia. An upsloping ST depression gets you 0 points for E.
History is the other crucial decision factor. There are two reasons the history is concerning to me:
Exertional angina or anginal equivalent. This means the symptom started with exertion, and improved with rest. This is more important than what the actual symptom was. Heartburn, belching, pressure, tightness, shortness of breath, diaphoresis, vomiting, severe fatigue, I-just-didn’t-feel-right… it doesn’t matter. If usual exertion produced unusual symptoms, that is very worrisome.
Active chest pain that looks like heart attack. If you walk into a room and the first thing you think is “heart attack,” you are done. Don’t let a HEART score make you reconsider.
Putting it together
E + H = 2: This is NSTE-ACS. If the troponin is positive, this is now NSTEMI. In either case, start heparin and push for immediate cath, or at least urgent cath. The RITA 3 trial supports routine cath for these cases for short-term mortality benefit. The survival gain at 5 years is gone at 10 years on follow-up. Pundits are arguing. I don’t care. 10 year survival isn’t in my EM mindset.
E + H = 1: Admit the patient and consult cardiology for further recommendations. Active chest pain should get heparin and a cath, in my opinion. But I am willing to follow cardiologist recommendations.
E + H = 0: Call cardiology for recommendations and come up with a mutual decision between you, the cardiologist, and the patient. I love shared decision making. There is very little benefit in observation admissions for low risk patients in my opinion, so I am biased towards discharge. If the patient is reliable to follow up and a cardiologist is available and on board with the plan, discharge is appropriate. Whenever available, a cardiologist should be involved in all cases of chest pain where ACS is a possibility. I’m sorry to PCPs, but they are the reason why HEART scores were created.
If there is no reliable follow-up, I lean towards punting the risk upstairs.