title: Comparison of the HEART and TIMI Risk Scores for Suspected Acute Coronary Syndrome in the Emergency Department.
abstract: OBJECTIVE
  The emergency department evaluation for suspected acute coronary syndrome (ACS) is common, costly, and challenging. Risk scores may help standardize clinical care and screening for research studies. The Thrombolysis in Myocardial Infarction (TIMI) and HEART are two commonly cited risk scores. We tested the null hypothesis that the TIMI and HEART risk scores have equivalent test characteristics.
  
  
  METHODS
  We analyzed data from the Internet Tracking Registry of Acute Coronary Syndromes (i*trACS) from 9 EDs on patients with suspected ACS, 1999-2001. We excluded patients with an emergency department diagnosis consistent with ACS, or without sufficient data to calculate TIMI and HEART scores. The primary outcome was 30-day major adverse cardiovascular events, including all-cause death, acute myocardial infarction, and urgent revascularization. We describe test characteristics of the TIMI and HEART risk scores.
  
  
  RESULTS
  The study cohort included 8255 patients with 508 (6.2%) 30-day major adverse cardiovascular events. Receiver operating curve and reclassification analyses favored HEART [c statistic: 0.753, 95% confidence interval (CI): 0.733-0.773; continuous net reclassification improvement: 0.608, 95% CI: 0.527-0.689] over TIMI (c statistic: 0.678, 95% CI: 0.655-0.702). A HEART score 0-3 [negative predictive value (NPV) 0.982, 95% CI: 0.978-0.986; positive predictive value (PPV) 0.103, 95% CI: 0.094-0.113; likelihood ratio (LR) positive 1.76; LR negative 0.28] demonstrates similar or superior NPV/PPV/LR compared with TIMI = 0 (NPV 0.978, 95% CI: 0.971-0.983; PPV 0.077, 95% CI: 0.071-0.084; LR positive 1.28; LR negative 0.35) and TIMI = 0-1 (NPV 0.963, 95% CI: 0.958-0.968; PPV 0.102, 95% CI: 0.092-0.113; LR positive 1.73; LR negative 0.58).
  
  
  CONCLUSIONS
  The HEART score has better discrimination than TIMI and outperforms TIMI within previously published "low-risk" categories.
authors.affiliation: From the *Department of Emergency Medicine, Oregon Health and Science University, Portland, OR; †Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR; ‡Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH; §Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX; ¶Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC; ‖Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA; **Department of Emergency Medicine, University of California Davis, Sacramento, CA; ††Department of Emergency Medicine, Baylor College of Medicine, Houston, TX; and ‡‡Department of Emergency Medicine, Singapore General Hospital, Singapore.
authors.forename: Benjamin C
authors.initials: BC
authors.lastname: Sun
authors.forename: Amber
authors.initials: A
authors.lastname: Laurie
authors.forename: Rongwei
authors.initials: R
authors.lastname: Fu
authors.forename: Maros
authors.initials: M
authors.lastname: Ferencik
authors.forename: Michael
authors.initials: M
authors.lastname: Shapiro
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Lindsell
authors.forename: Deborah
authors.initials: D
authors.lastname: Diercks
authors.forename: James W
authors.initials: JW
authors.lastname: Hoekstra
authors.forename: Judd E
authors.initials: JE
authors.lastname: Hollander
authors.forename: J Douglas
authors.initials: JD
authors.lastname: Kirk
authors.forename: W Frank
authors.initials: WF
authors.lastname: Peacock
authors.forename: Venkataraman
authors.initials: V
authors.lastname: Anantharaman
authors.forename: Charles V
authors.initials: CV
authors.lastname: Pollack
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000453:epidemiology*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002318:Cardiovascular Diseases / Q000401:mortality*; D015331:Cohort Studies; D016208:Databases, Factual; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology*; D009204:Myocardial Revascularization / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012372:ROC Curve; D012042:Registries; D018570:Risk Assessment / Q000379:methods*