Use of the HEAR Score for 30-Day Risk-Stratification in Emergency Department Patients

Background: The 2021 ACC/AHA chest pain guidelines recommend risk scores such as HEAR (History, Electrocardiogram, Age, Risk Factors) for short term risk-stratification yet limited data exists integrating them with high-sensitivity cardiac troponin T (hs-cTnT). Methods: Retrospective, multicenter (n=2), observational, U.S. cohort study of consecutive ED patients without ST-elevation myocardial infarction (MI) who had at least one hs-cTnT (limit of quantitation, LoQ, <6 ng/L, and sex-specific 99th percentiles of 10 ng/L for women and 15 ng/L for men) measurement on clinical indications in whom HEAR scores (0-8) were calculated. The composite major adverse cardiovascular (MACE) outcome was 30-day prognosis. Results: Among 1,979 ED patients undergoing hs-cTnT measurement, 1045 (53%) were low-risk (0-3), 914 (46%) intermediate-risk (4-6), and 20 (1%) high-risk (7-8) based on HEAR scores. HEAR scores were not associated with increased risk of 30-day MACE in adjusted analyses. Patients with quantifiable hs-cTnT (LoQ-99th) had an increased risk for 30-day MACE (3.4%) irrespective of HEAR scores. Those with serial hs-cTnT<99th percentile remained at low-risk (range 0% to 1.2%) across all HEAR score strata. Higher scores were not associated with long term (2-year) events. Conclusions: HEAR scores are of limited value in those with baseline hs-cTnT99th percentile to define short term prognosis. In those with baseline quantifiable hs-cTnT within the reference range (<99th percentile), a higher risk (>1%) for 30-day MACE exists even in those with low HEAR scores. With serial hs-cTnT measurements, HEAR scores overestimate risk when hs-cTnT remains <99th percentile.