What scoring criteria can be used to aid in assessing admitted patients with chest pain?

Scoring Criteria for Assessing Admitted Patients with Chest Pain

The HEART score is the most effective and validated scoring system for risk stratification of admitted patients with chest pain, with high sensitivity for predicting major adverse cardiac events (MACE). 1, 2

Key Risk Stratification Scores

HEART Score

The HEART score consists of five components, each scored 0-2 points (maximum 10 points):

• History (0-2 points based on suspicion level)
• ECG (0-2 points based on ischemic changes)
• Age (0-2 points: <45=0,45-65=1, >65=2)
• Risk factors (0-2 points based on number of risk factors)
• Troponin (0-2 points based on elevation) 1, 2, 3

Risk stratification using HEART score:

• Low risk (0-3): 2.5% risk of MACE, supports discharge
• Intermediate risk (4-6): 20.3% risk of MACE, requires observation
• High risk (≥7): 72.7% risk of MACE, supports early invasive strategies 2, 4

Other Validated Scoring Systems

1. GRACE Risk Score:

   • Predicts in-hospital and post-discharge mortality/MI
   • Components: age, heart failure, peripheral vascular disease, systolic BP, Killip class, creatinine, cardiac biomarkers, cardiac arrest, ST-segment deviation
   • Score range: 0-363 1

2. EDACS Score:

   • Components: age, sex, known CAD, risk factors, symptoms
   • Score range: -8 to 34
   • Identifies low-risk patients suitable for early discharge 1

3. TIMI Risk Score:

   • Components: age, CAD risk factors, known CAD, ASA use, severe angina, ECG changes, positive cardiac markers
   • Often combined with troponin testing for better accuracy 1

4. T-MACS Score:

   • Components: sweating, systolic BP <100 mmHg, pain radiation to right arm/shoulder, chest discomfort with vomiting, worsening angina, acute ischemia on ECG, troponin level
   • Score range: 0-7 (0 points = eligible for immediate discharge) 1

Implementation in Clinical Practice

High-Sensitivity Troponin-Based Protocols

• 0/1h Protocol: Serial high-sensitivity troponin measurements at 0 and 1 hour
• 0/2h Protocol: Serial measurements at 0 and 2 hours
• 0/3h Protocol: Serial measurements at 0 and 3 hours 1

Risk Stratification Categories

Based on the 2021 AHA/ACC guidelines, patients should be classified as:

1. Low Risk (<1% 30-day risk for death or MACE):

   • Initial high-sensitivity troponin below detection limit or "very low" threshold if symptoms present for at least 3 hours
   • 0/1h or 0/2h delta both below assay "low" thresholds 1

2. Intermediate Risk:

   • HEART score 4-6
   • Initial high-sensitivity troponin between "low" and "high" thresholds
   • 1h or 2h troponin delta between low and high thresholds 1, 3

3. High Risk:

   • HEART score 7-10
   • New ischemic ECG changes
   • Troponin-confirmed acute myocardial injury
   • New-onset LV systolic dysfunction (EF <40%)
   • Newly diagnosed moderate-severe ischemia on stress testing
   • Hemodynamic instability 1

Clinical Application and Pitfalls

Common Pitfalls to Avoid

• Overreliance on a single parameter: No single element should determine risk classification 3
• Ignoring clinical context: Risk scores should supplement, not replace, clinical judgment 3
• Missing serial ECG changes: Serial ECGs are crucial when initial ECG is nondiagnostic 1
• Misinterpreting troponin changes: Small fluctuations may reflect assay imprecision rather than acute cardiac injury 1

Special Considerations

• Prehospital assessment: Modified HEART scores can be calculated in the field with high NPV (98.1%) for 30-day MACE 5
• Multinational validation: HEART score has been validated across different populations with consistent results (C-statistic 0.83) 6
• Integration with imaging: For intermediate-risk patients with known CAD, stress imaging (PET/SPECT MPI, CMR, or stress echocardiography) is reasonable 1

Management Based on Risk Stratification

• Low-risk patients: Consider early discharge without additional testing 1, 3
• Intermediate-risk patients: Observation with serial troponin testing and possible stress testing 1
• High-risk patients: Invasive coronary angiography is recommended 1

By systematically applying these validated scoring criteria, clinicians can effectively risk-stratify patients with chest pain and determine appropriate management strategies while minimizing unnecessary testing and admissions.