title: The predictive value of the exercise ECG for major adverse cardiac events in patients who presented with chest pain in the emergency department.
abstract: BACKGROUND
  To improve early diagnostic and therapeutic decision making, we designed the HEART score for chest pain patients in the emergency department (ED). HEART is an acronym of its components: History, ECG, Age, Risk factors and Troponin. Currently, many chest pain patients undergo exercise testing on the consecutive days after presentation. However, it may be questioned how much diagnostic value the exercise ECG adds when the HEART score is already known.
  
  
  METHODS
  A subanalysis was performed of a multicenter prospective validation study of the HEART score, consisting of 248 patients who underwent exercise testing within 7 days after presentation in the ED. Outcome is the predictive value of exercise testing in terms of major adverse cardiac events (MACE) within 6 weeks after presentation.
  
  
  RESULTS
  In low-risk patients (HEART score ≤ 3), 63.1 % were negative tests, 28.6 % non-conclusive and 8.3 % positive; the latter were all false positives. In the intermediate-risk group (HEART score 4-6), 30.9 % were negative tests, 60.3 % non-conclusive and 8.8 % positive, half of these positives were false positives. In the high-risk patients (HEART score ≥ 7), 14.3 % were negative tests, 57.1 % non-conclusive and 28.6 % positive, of which half were false positives.
  
  
  CONCLUSIONS
  In a chest pain population risk stratified with HEART, exercise testing has only a modest contribution to clinical decision making. 50 % of all tests are non-conclusive, with high rates of false positive tests in all three risk groups. In intermediate-risk patients, negative exercise tests may contribute to the exclusion of disease. Clinicians should rather go for sensitive tests, in particular in patients with low HEART scores.
authors.affiliation: Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands. j.poldervaart@umcutrecht.nl
authors.forename: Judith M
authors.initials: JM
authors.lastname: Poldervaart
authors.forename: A Jacob
authors.initials: AJ
authors.lastname: Six
authors.forename: Barbra E
authors.initials: BE
authors.lastname: Backus
authors.forename: Hector W L
authors.initials: HW
authors.lastname: de Beaufort
authors.forename: Maarten-Jan M
authors.initials: MJ
authors.lastname: Cramer
authors.forename: Rolf F
authors.initials: RF
authors.lastname: Veldkamp
authors.forename: E
authors.initials: E
authors.lastname: Gijs Mast
authors.forename: Eugène M
authors.initials: EM
authors.lastname: Buijs
authors.forename: Wouter J
authors.initials: WJ
authors.lastname: Tietge
authors.forename: Björn E
authors.initials: BE
authors.lastname: Groenemeijer
authors.forename: Luc
authors.initials: L
authors.lastname: Cozijnsen
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Wardeh
authors.forename: Hester M
authors.initials: HM
authors.lastname: den Ruiter
authors.forename: Pieter A
authors.initials: PA
authors.lastname: Doevendans
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis*; D000328:Adult; D000367:Age Factors; D000368:Aged; D002637:Chest Pain / Q000209:etiology*; D003657:Decision Making; D004562:Electrocardiography / Q000379:methods; D004636:Emergency Service, Hospital; D005080:Exercise Test / Q000379:methods*; D005189:False Positive Reactions; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012307:Risk Factors; D014336:Troponin / Q000378:metabolism
chemical_list: D014336:Troponin