MedicalResearch.com Interview with:
Judith Poldervaart MD, PhD
Julius Center for Health Sciences and Primary Care
University Medical Center
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: Since its development in 2008, interest in the HEART score is increasing and several research groups around the world have been publishing on the HEART score. After validation of any risk score for cardiac events, there is a concern about the safety when used in daily practice.
We were able to show the HEART score is just as safe as the usual care currently used at EDs, which has not been shown yet in previous research. That we did not find a decrease in costs, is probably due to the hesitance of physicians to discharge low-risk patients from the ED without further testing. But extrapolation of the findings of a cost-effectiveness analysis (including nonadherence) suggests that HEART care could lead to annual savings of €40 million in the Netherlands. Hopefully, in time (and more publications of the HEART score now appearing almost weekly from all over the world) this effect on use of health care resources will become more apparent.
MedicalResearch.com: What should readers take away from your report?
Response: The routine use of the HEART score during the initial assessment of chest pain patients at the emergency department was just as safe as usual care. It is likely that with increasing acceptance, confidence and experience with the HEART score, the impact on health care resources and costs increases. Barriers for use should be addressed, and we should as a society decide on what risk of cardiac events we find acceptable in low-risk patients, balancing this against the risk for complications from redundant testing.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Response: Further research should focus on identifying low-risk patients, since the main barriers to follow the rule are in these patients, and at the same time this is the group were considerable reduction in the use of health care resources and harm of overdiagnosis to low-risk patients can be achieved. This excellent editorial describes this current dilemma of physicians in chest pain patients, resulting in harm in patients in terms of overdiagnosis and overtreatment. (Brace-McDonnell SJ, Laing S. When is low-risk chest pain acceptable risk chest pain? Heart. 2014;100(18):1402-3.)
MedicalResearch.com: Is there anything else you would like to add?
Response: The HEART score is a decision support tool, not a strict protocol. Patients presenting at the ED with chest pain should be assessed by a physician, using clinical parameters of the patients, his experience, gut feeling, complemented by the HEART score. The HEART score is an accurate tool, but is no gold standard (just as usual care has no 100% sensitivity). For example, when a patient with an elevated troponin has only 2 points, of course a physician can deviate from the proposed policy of discharge. The HEART score is no replacement for clinical judgment, but an extra tool for physicians to make informed decisions for individual patients.
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Poldervaart JM, Reitsma JB, Backus BE, Koffijberg H, Veldkamp RF, ten Haaf ME, et al. Effect of Using the HEART Score in Patients With Chest Pain in the Emergency Department: A Stepped-Wedge, Cluster Randomized Trial. Ann Intern Med. [Epub ahead of print 25 April 2017] doi: 10.7326/M16-1600
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