Clinical decision instruments for sorting out chest
pain are nothing new. The latest craze seems to be the HEART score.
Who would have thought it helpful to consider the history, ECG, age, risk
factors and troponin?
Ok, it seems to have face validity. But is it an improvement
upon what we are currently doing? This is an essential question for any
decision instrument.
This prospective cohort study out of the Netherlands
compared the diagnostic accuracy of the HEART score vs. gestalt in 255
patients.
Results? A
whopping 29% of patients had ACS (I think the Dutch have been eating too much cheese.) The HEART score and gestalt seemed to have similar diagnostic accuracy.
Has the HEART score suffered an MI?
Maybe...
To be fair, this study was underpowered and the trends favoured
the HEART score. In addition, the doctors specifying their gestalt risk of
ACS (low, intermediate, or high) also had to calculate the HEART score! The
authors duly noted this and dubbed it possible “influencing bias.” No wonder there was no difference.
As Dr
Jerry Hoffman has stated numerous times, clinical decision instruments tend
to work poorly in complex disease processes. We are probably never going to
come up with a simple and good quality rule that can replace the complexity &
nuance of ED chest pain evaluation.
Perhaps the enthusiasm coming from the USA stems from the
desire to have some objective quantitative measure charted to justify sending
someone home? Shoooooo lawyer you!
Despite the enthusiasm on social media, I’ve never used the
HEART score and I know I’m not alone.
Wait a second... history, ECG, age, risk factors and troponin?
I take it back... I’ve been using it all the time without knowing! I'm so clever...
Covering:
Visser A,
Wolthuis A, Breedveld R, et al. HEART score and clinical gestalt have similar
diagnostic accuracy for diagnosing ACS in an unselected population of patients
with chest pain presenting to the ED. Emerg Med J 2015;32:595-600.
No comments:
Post a Comment