Effect of using the HEART score in patients with chest pain in the emergency department: A Stepped-wedge, cluster randomized trial

Judith M. Poldervaart, Johannes B. Reitsma, Barbra E. Backus, Hendrik Koffijberg, Rolf F. Veldkamp, Monique E. Ten Haaf, Yolande Appelman, Herman F.J. Mannaerts, Jan Melle van Dantzig, Madelon Van Den Heuvel, Mohamed El Farissi, Bernard J.W.M. Rensing, Nicolette M.S.K.J. Ernst, Ineke M.C. Dekker, Frank R. Den Hartog, Thomas Oosterhof, Ghizelda R. Lagerweij, Eugene M. Buijs, Maarten W.J. Van Hessen, Marcel A.J. LandmanRoland R.J. Van Kimmenade, Luc Cozijnsen, Jeroen J.J. Bucx, Clara E.E. Van Ofwegen-Hanekamp, Maarten Jan Cramer, A. Jacob Six, Pieter A. Doevendans, Arno W. Hoes

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152 Citations (Scopus)


Background: The HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score is an easy-to-apply instrument to stratify patients with chest pain according to their short-term risk for major adverse cardiac events (MACEs), but its effect on daily practice is unknown.
Objective: To measure the effect of use of the HEART score on patient outcomes and use of health care resources.
Design: Stepped-wedge, cluster randomized trial. (Clinical Trials.gov: NCT01756846)
Setting: Emergency departments in 9 Dutch hospitals. Patients: Unselected patients with chest pain presenting at emergency departments in 2013 and 2014. Intervention: All hospitals started with usual care. Every 6 weeks, 1 hospital was randomly assigned to switch to "HEART care," during which physicians calculated the HEART score to guide patient management.
Measurements: For safety, a noninferiority margin of a 3.0% absolute increase in MACEs within 6 weeks was set. Other outcomes included use of health care resources, quality of life, and cost-effectiveness.
Results: A total of 3648 patients were included (1827 receiving usual care and 1821 receiving HEART care). Six-week incidence of MACEs during HEART care was 1.3% lower than during usual care (upper limit of the 1-sided 95% CI, 2.1% [within the noninferiority margin of 3.0%]). In low-risk patients, incidence of MACEs was 2.0% (95% CI, 1.2% to 3.3%). No statistically significant differences in early discharge, readmissions, recurrent emergency department visits, outpatient visits, or visits to general practitioners were observed. Limitation: Physicians were hesitant to refrain from admission and diagnostic tests in patients classified as low risk by the HEART score. Conclusion: Using the HEART score during initial assessment of patients with chest pain is safe, but the effect on health care resources is limited, possibly due to nonadherence to management recommendations.
Original languageEnglish
Pages (from-to)689-697
Number of pages9
JournalAnnals of Internal Medicine
Issue number10
Publication statusPublished - 16 May 2017


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