title: Identifying patients for early discharge: performance of decision rules among patients with acute chest pain.
abstract: BACKGROUND
  The HEART score and North American Chest Pain Rule (NACPR) are decision rules designed to identify acute chest pain patients for early discharge without stress testing or cardiac imaging. This study compares the clinical utility of these decision rules combined with serial troponin determinations.
  
  
  RESULTS
  A secondary analysis was conducted of 1005 participants in the Myeloperoxidase In the Diagnosis of Acute coronary syndromes Study (MIDAS). MIDAS is a prospective observational cohort of Emergency Department (ED) patients enrolled from 18 US sites with symptoms suggestive of acute coronary syndrome (ACS). The ability to identify participants for early discharge and the sensitivity for ACS at 30 days were compared among an unstructured assessment, NACPR, and HEART score, each combined with troponin measures at 0 and 3h. ACS, defined as cardiac death, acute myocardial infarction, or unstable angina, occurred in 22% of the cohort. The unstructured assessment identified 13.5% (95% CI 11.5-16%) of participants for early discharge with 98% (95% CI 95-99%) sensitivity for ACS. The NACPR identified 4.4% (95% CI 3-6%) for early discharge with 100% (95% CI 98-100%) sensitivity for ACS. The HEART score identified 20% (95% CI 18-23%) for early discharge with 99% (95% CI 97-100%) sensitivity for ACS. The HEART score had a net reclassification improvement of 10% (95% CI 8-12%) versus unstructured assessment and 19% (95% CI 17-21%) versus NACPR.
  
  
  CONCLUSIONS
  The HEART score with 0 and 3 hour serial troponin measures identifies a substantial number of patients for early discharge while maintaining high sensitivity for ACS.
authors.affiliation: Wake Forest School of Medicine, Winston-Salem, NC, USA. Electronic address: smahler@wakehealth.edu.
authors.forename: Simon A
authors.initials: SA
authors.lastname: Mahler
authors.forename: Chadwick D
authors.initials: CD
authors.lastname: Miller
authors.forename: Judd E
authors.initials: JE
authors.lastname: Hollander
authors.forename: John T
authors.initials: JT
authors.lastname: Nagurney
authors.forename: Robert
authors.initials: R
authors.lastname: Birkhahn
authors.forename: Adam J
authors.initials: AJ
authors.lastname: Singer
authors.forename: Nathan I
authors.initials: NI
authors.lastname: Shapiro
authors.forename: Ted
authors.initials: T
authors.lastname: Glynn
authors.forename: Richard
authors.initials: R
authors.lastname: Nowak
authors.forename: Basmah
authors.initials: B
authors.lastname: Safdar
authors.forename: Mary
authors.initials: M
authors.lastname: Peberdy
authors.forename: Francis L
authors.initials: FL
authors.lastname: Counselman
authors.forename: Abhinav
authors.initials: A
authors.lastname: Chandra
authors.forename: Joshua
authors.initials: J
authors.lastname: Kosowsky
authors.forename: James
authors.initials: J
authors.lastname: Neuenschwander
authors.forename: Jon W
authors.initials: JW
authors.lastname: Schrock
authors.forename: Stephen
authors.initials: S
authors.lastname: Plantholt
authors.forename: Deborah B
authors.initials: DB
authors.lastname: Diercks
authors.forename: W Frank
authors.initials: WF
authors.lastname: Peacock
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002637:Chest Pain / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy*; D015331:Cohort Studies; D003657:Decision Making; D004636:Emergency Service, Hospital / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge / Q000592:standards*; D011446:Prospective Studies; D012720:Severity of Illness Index; D013997:Time Factors
keywords: Acute coronary syndrome; Chest pain; Clinical decision rules; Risk stratification