Performance of the HEART Score in pre-hospital settings for suspected non-ST-elevation acute coronary syndrome: The POPular HEART Study

Background The HEART (history, ECG, age, risk factors, and troponin) score is used to stratify patients with chest pain into low- or higher-risk for major adverse cardiac events (MACE). We assessed the diagnostic performance and interobserver agreement of the pre-hospital HEART score for ruling out myocardial infarction (MI) and MACE. Methods This prospective, multicentre study included 383 patients with suspected non-ST-elevation acute coronary syndrome. Patients with both a pre-hospital and in-hospital HEART scores were analysed (n = 331). Prehospital HEART scores (based on point-of-care troponin) were assessed by ambulance personnel, and in-hospital HEART scores (based on the European Society of Cardiology 0/1-hour high-sensitivity troponin algorithm) were assessed by emergency physicians blinded to the pre-hospital scores. Endpoints were interobserver agreement (intraclass correlation coefficient, ICC) and diagnostic performance for ruling out MI and MACE at 30 days. Results Among the 331 patients (mean age: 65 years, 48% women), 26% were classified as low risk (pre-hospital HEART <= 3) of whom 4.7% had an index-admission NSTEMI. Of the patients with HEART score > 3, 12.1% experienced MACE. Interobserver agreement between the pre- and in-hospital HEART scores was moderate (ICC, 0.653), with the lowest concordance for history and ECG. The pre-hospital HEART score yielded a negative predictive value of 95.33% and a sensitivity of 91.7% for MACE at 30 days. Conclusion Pre- and in-hospital HEART scores showed moderate agreement. The 30-day MACE rate (4.7%) in the pre-hospital low-risk group indicates that improved training in history and ECG assessment, and use of high-sensitivity assays are required.