Prehospital Comparison of the HEAR and HE-MACS Scores for 30-Day Adverse Cardiac Events

Abstract

Objective

The History, Electrocardiogram (ECG), Age, and Risk factor (HEAR) and History and ECG-only Manchester Acute Coronary Syndromes (HE-MACS) risk scores can risk stratify chest pain patients without troponin measures. The objective of this study was to determine if either risk score could achieve the ≥99% negative predictive value (NPV) required to rule out major adverse cardiovascular events (MACE; a composite of all-cause death, myocardial infarction, or coronary revascularization) at 30 days or the ≥50% positive predictive value (PPV) indicative of a patient possibly needing interventional cardiology.

Methods

We performed a pre-planned secondary analysis of the prospective multisite PARAHEART (n = 462, 12/2016-1/2018) and RESCUE (n = 767, 4/2018-1/2019) trials, which accrued adults ≥21 years old with acute non-traumatic chest pain transported by emergency medical services (EMS). Paramedics prospectively completed risk assessment forms. Very low risk was defined by a HEAR score of 0-1 or HE-MACS probability <4%. The primary outcome was 30-day MACE, which was determined by adjudication (PARAHEART) or electronic record review (RESCUE). NPV and PPV with exact 95% confidence intervals (95%CI) for 30-day MACE were calculated for each risk score and compared using McNemar’s tests.

Results

Among the PARAHEART and RESCUE cohorts, 30-day MACE occurred in 18.8% (87/462) and 6.9% (53/767) of patients, respectively. In PARAHEART, 7.8% (36/462) were very low risk by HEAR score vs. 7.8% (36/462) by HE-MACS (p = 1.0). The HEAR score had a NPV of 97.2% (95%CI 91.9-100.0) vs. 91.7% (95%CI 82.6-100.0) for HE-MACS (p = 0.15). The HEAR and HE-MACS PPVs were similar [46.4% (95%CI 28.0-64.9) vs. 33.3% (95%CI 13.2-53.5) (p = 0.26)]. In RESCUE, the HEAR score identified 14.2% (109/767) as low risk compared to 8.3% (64/767) by HE-MACS (p < 0.001). In this cohort, the HEAR and HE-MACS scores had similar NPVs [98.2% (95%CI 95.7-100.0) vs. 98.4% (95%CI 95.4-100.0) (p = 0.89)] and PPVs [16.2% (95%CI 6.2-32.0) vs. 22.6% (95%CI 12.3-36.2) (p = 0.41)].

Conclusions

In two prehospital chest pain cohorts, neither the HEAR score nor HE-MACS achieved sufficient NPV or PPV to rule out or rule in 30-day MACE.

Acknowledgments

We appreciate Brian Hehl and Matthew Wells supporting this work.

Disclosure statement

Dr. Ashburn receives funding from NHLBI (T32HL076132). Dr. Snavely receives funding from Abbott Laboratories and HRSA (1H2ARH399760100). Dr. O’Neill receives funding from Cytovale, Wake Forest CTSI (55811085045501.10000449805), and NCATS. Dr. Body has received research grants from Abbott Point of Care and Siemens Healthineers, and has consulted for Roche, Siemens, Abbott, Beckman Coulter, Radiometer, Aptamer Group, LumiraDx and Psyros. Dr. Stopyra receives research funding from NCATS/NIH (KL2TR001421), HRSA (H2ARH39976-01-00), Roche Diagnostics, Abbott Laboratories, Pathfast, Genetesis, Cytovale, Forest Devices, Vifor Pharma, and Chiesi Farmaceutici. Dr. Mahler receives funding/support from Roche Diagnostics, Abbott Laboratories, Ortho Clinical Diagnostics, Siemens, Grifols, Pathfast, Quidel, Genetesis, Cytovale, and HRSA (1H2ARH399760100). He is a consultant for Roche, Quidel, Abbott, Genetesis, Inflammatix, Radiometer, and Amgen, and the chief medical officer for Impathiq Inc.

Funding

No funding was received for this project.

Data availability statement

Data sharing is not applicable to this article as no new data were created or analyzed in this study.