INTRODUCTION: Chest pain (CP), a common presentation in the emergency department (ED) setting, is associated with significant morbidity and mortality if emergency clinicians miss the diagnosis of acute coronary syndrome (ACS). The HEART (History, Electrocardiogram, Age, Risk Factors, Troponin) score had been validated for risk-stratification patients who are at high risk for ACS and major adverse cardiac events (MACE). However, the use of cocaine as a risk factor of the HEART score was controversial. We hypothesized that patients with cocaine-positive (COP) would not be associated with higher risk of 30-day MACE than cocaine-negative (CON) patients.
METHODS: This retrospective study included adult patients who presented to 13 EDs of a University's Medical System between August 7, 2017 to August 19, 2021. Patients who had CP and prospectively calculated HEART scores and urine toxicology tests as part of their clinical evaluation were eligible. Areas Under The Receiver Operating Curve (AUROC) were calculated for the performance of HEART score and 30-day MACE for each group.
RESULTS: This study analyzed 46,210 patients' charts, 663 (1.4%) were COP patients. Mean age was statistically similar between groups but there were fewer females in the COP group (26.2% vs 53.2%, p < 0.001). Mean (+/- SD) HEART score was 3.7 (1.4) comparing to 3.1 (1.8, p < 0.001) between COP vs CON groups, respectively. Although more COP patients (54%) had moderate HEART scores (4-6) vs. CON group (35.2%, p < 0.001), rates of 30-day MACE were 1.1% for both groups. HEART score's AUROC was 0.72 for COP and 0.78 for CON groups. AUROC for the Risk Factor among COP patients, which includes cocaine, was poor (0.54).
CONCLUSION: This study, which utilized prospective calculated HEART scores, demonstrated that overall performance of the HEART score was reasonable. Specifically, our analysis showed that the rate of 30-day MACE was not affected by cocaine use as a risk factor. We would recommend clinicians to consider the HEART score for this patient group.
| Discipline Area | Score |
|---|---|
| Physician |  |
Physician rater
It is unclear whether they captured all the MACE patients. I suspect their conclusion is correct "that the prevalence of 30-day MACE for patients who presented to ED with chest pain and positive cocaine in urine toxicology tests was the same as patients who tested negative for cocaine."
Physician rater
The current standard of care encourages providers to use the HEART score when patients present with chest pain regardless of substance use. I do not know why the study needed to be done since it was not going to change the standard in any way. ER physicians and other providers would continue to use this risk stratification tool if the study had found a significant reduction in the incidence of MACE in cocaine users.
Physician rater
The relative low-intermediate risk of 30-day MACEs may limit the validity of this study when used in patients with intermediate-high risk. The main limitation seems to be the low number of MACEs in both groups, reflecting the relatively low risk of MACE according to the HEART score.
, McMaster University