Thursday 8 September 2016

HEART Score vs. Gestalt for Diagnosing ACS in the ED?

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?


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...


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.

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