Modified HEART as Rule Out for Suspected ACS
Modified HEART as Rule Out for Suspected ACS
Validation of modified HEART score as a rule-out criterion for MACE at 6 weeks: a 2 centre
 prospective observational cohort with a direct comparison to TIMI, GRACE and high sensitive
 troponin T at limits of detection

 Detailed description:

 The HEART score, as defined previously by Backus et al1, is a risk score specifically
 developed for acute chest pain/ suspected acute coronary syndrome. The conventional scoring
 system for the troponin component of HEART is as follows: Troponin <99th percentile =0 (in
 the case of Hstn T [Roche} 14ng/l, 99th percentile up to X3 URL (99th percentile)= 1 (HSTN T
 =14-42ng/L, >x3 URN =2 (HSTN T >42ng/l).

 We have previously defined that the optimal rule-out strategy for suspected acute coronary
 syndromes may well be a modified HEART score in a single centre study. This study is to
 prospectively validate the use of this score in a prospective unselected cohort of patients
 with possible acute coronary syndrome at 2 large secondary care centres
Validation of modified HEART score as a rule-out criterion for MACE at 6 weeks: a 2 centre
 prospective observational cohort with a direct comparison to TIMI, GRACE and high sensitive
 troponin T at limits of detection

 Detailed description:

 The HEART score, as defined previously by Backus et al1, is a risk score specifically
 developed for acute chest pain/ suspected acute coronary syndrome. The conventional scoring
 system for the troponin component of HEART is as follows: Troponin <99th percentile =0 (in
 the case of Hstn T [Roche} 14ng/l, 99th percentile up to X3 URL (99th percentile)= 1 (HSTN T
 =14-42ng/L, >x3 URN =2 (HSTN T >42ng/l).

 the investigators previously defined that the optimal rule-out strategy for suspected acute
 coronary syndromes may well be a modified HEART score in a single centre study. This study is
 to prospectively validate the use of this score in a prospective unselected cohort of
 patients with possible acute coronary syndrome at 2 large secondary care centres. The second
 centre (Royal Liverpool University Hospital) was external to where the initial cohort of 1642
 patients were assessed that defined modified HEART as the optimal score.

 The modified HEART score is as follows: HEART score can be re-calibrated (modified HEART) to
 undetectable hstnT and 99th percentile limits (<5= 0, ≥5-14=1, >14=2).

 Troponin (HSTnT) Roche (elecsys) >14ng/l 2 5-14ng/l 1 <5ng/l 0

 This 2 centre study will enrol consecutive patients with suspected acute coronary syndrome
 (defined as physician suspicion of ischaemic chest pain resulting in sampling of High
 sensitive troponin and undertaking an electrocardiogram at presentation).

 For all troponin positive patients (HSTnT>14ng/l) the diagnosis will be adjudicated centrally
 with at least 2 'blinded' clinicians. The outcome will be MACE at 6 weeks. MACE will be
 defined by acute myocardial infarction, urgent or emergency coronary revascularisation and
 all cause death.

 Power calculations (provided by clinical trials, university of Liverpool):

 Assuming:

 Prevalence of MACE events in the population with suspected ACS is 12.5% (as in MACROS) The
 anticipated sensitivity is 0.98 The acceptable value for the 95% confidence interval for
 sensitivity is 0.95 The power of the study is 80%

 Then the number of events needed would be approximately 150. Thus 150/0.125 = 1200 suspected
 ACS admission would need to be enrolled

 The study has been assessed by research boards at both hospitals and has been registered as
 an audit, with the primary aim of quality control of a novel accelerated chest pain pathway
 that has been recently implemented at both hospitals. The study does not require
 individualised patient consent and is supported by the Caldicott Guardian.

 Secondary aims of the study are to compare the performance of modified HEART score with
 modified TIMI < or equal to 1 or 0 and modified GRACE score < or equal to 75 in terms of rule
 out for MACE at 6 weeks The investigators compare the 'performance' of modified HEART with
 the use of undetectable HSTnT <5ng/l (combined with a nonischaemic ECG). The latter is part
 of the recently adopted chest pain pathway at both recruiting hospitals with clear guidance
 of discharge at presentation for patients with chest pain who have an undetectable HSTnT and
 nonischaemic ECG. Therefore it will allow the research team to compare modified HEART virtual
 discharge with actual (rather than virtual) discharge for an approach based on undetectable
 HSTnT.
Inclusion Criteria:consecutive presentations to A&E at 2 major urban hospital swith chest
 pain that the clinicans feel warrants a biomarker check for myocyte necrosis (high
 sensitive troponin) and presentation ECG

 -

 Exclusion Criteria:

 primary presentation not chest pain

 clear noncardiac cause of chest pain such as trauma life expectancy <1 year due to
 noncardiac pathology