Amal Mattu on Low Risk Chest Pain

Something very cool is happening in emergency medicine, specifically low risk chest pain. What I mean by that is figuring out who is low risk and what to do about it. This is one of the biggest areas of CYA, for the uninitiated, cover your ass, medicine. And for good reason, it’s a big cause of lawsuits and if we get it wrong, people can die. We just had two episodes on cardiac CT addressing this very topic and one thing that came up in the last show with Rory Spiegel, was that the Cardiac CT did not perform any better than just using risk assessment and cardiac enzymes. But what does that mean? What is risk assessment in the ED? Is it, “Holy moly, that sounds like cardiac chest pain for sure, bang, you’re admitted.” Or is it, “C’mon, that’s not cardiac chest pain.” Well, that’s indeed a small part of it, but there has been improvement on assessing risk using enzymes and risk scores. The TIMI score has been out there for a while but it’s not as nuanced an instrument as we’d like. The HEART score may be a better and more usable tool in the ED.

 


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We are hungry for a sensible, safe and consistent pathway for evaluating chest pain. A new chest pain ADP has emerged from from the primordial soup, and it comes from none other Dr. Amal Mattu. Here is a link to Amal’s full explanation of the ADP and chest pain risk assessment and I recommend you to listen to it to get the full flavor of what he’s talking about. But for now, a  recap….

Many chest pain pathways have relied on the TIMI score, but that is a somewhat cumbersome tool for our needs. The HEART score shows promise as a decision instrument with more utility in the emergency department. The HEART score uses 5 criteria: history, EKG, age, risk factors, and troponin to determine risk of a 6 week major adverse cardiac event. Each one of these pieces has three parts. For example, risk factors: no risk factors, zero points; 1-2 risk factors, 1 point; 3 or more risk factors, 2 points. If a patient has everything, everything positive in the heart score, that’s 10 points -high risk. Low risk is 3 points or less. A low risk score gives a 1.7% 30 day risk of major adverse event. Add in a second negative (delta) troponin, and the risk goes down to under 1%.

Links for this episode

Amal Mattu’s full explanation of Chest Pain ADP, Low risk chest pain, medico-legal aspects of chest pain, chest pain guidelines

University of Maryland Low Risk Chest Pain ADP

Shared Decision Making Graphic

Heart Score Calculator 

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Comments

  1. dc

    Curious whether in deriving the HEART score they found any difference regarding onset of chest pain and troponin results. all i could see from the articles were that they drew the troponins on admission to the ED. So are they implying that timing of CP does not matter for troponin interpretation?

    1. Mike Hodgman

      It appears they used whatever troponin was done at the study hospital (there were 10 in the validation study). The new ultrasensitive assays will likely make this tool less specific. From table 3, 3.4% of the no major adverse cardiac event within 6 weeks group had a tropi score of two, meaning > 3x upper limit normal. I think I’d have a hard time sending any of these out (exception might be chronic renal failure patient with chronically modest elevation in tropi, there I’d look for a delta trop in ED). But the table shows that what really matters in ED assessment hierarchy are tropi, EKG, history and less important are age and risk factors.

  2. GTB

    In looking at the protocol, it is recommended to admit a patient with an increasing and/or +ve troponin. How are you managing the patients which have a trivial rise in their troponin that is still below the cutoff? Ex: Our lab cutoff is 0.04, how would a patient whose troponin rose from 0.01 to 0.03 be dispositioned with this protocol?

  3. Pierre Mikhail

    I always enjoy ERCAST and Dr. Mattu. As a Canadian, I am constantly grateful that I don’t work in an environment where disposition decisions seem to be driven MOST by fear of litigation.

    We heard that the HEART Score and one negative troponin portends a 2% risk at 45 days of MACE and that if you add a second troponin at 3 hours that risk decreases to 1%. I am not entirely sure that we know if that number is better than a good clinician using no rule and two markers in the real world. Also, Dr. Mattu stated that this approach has avoided admission in 20% of low risk chest pain patients. Since I (and I would suspect most of my Canadian colleagues) admit close to 0% of LOW RISK chest pain patients, I am not sure that this helps me at all. And what about the harm caused to low risk patients that have downstream testing done? I don’t think we have any evidence that admitting low risk chest pain protects them from anything but I’m pretty certain it is associated with a much higher rate of downstream testing which is not benign.

    I’d be interested in knowing what the incidence of clinically relevant bad outcomes are in low risk patients sent home….. in other words, if you are sent home, but return with a more worrisome presentation that clarifies the diagnostic pathway (ie this time you present with ECG changes), is there anything wrong with that? As long as we are not sending people home in large numbers that have actual bad outcomes like death or MIs causing LV dysfunction, maybe it’s ok not to be 100% perfect?

    1. Post
      Author
      Rob Orman

      Hi Pierre, here is the response from Dr. Mattu….

      Yes, clinical gestalt is fantastic in an experienced, well-read provider. Not everyone fits into that description, so the HEART score and other scoring systems can certainly help those people that are not as experienced.
      I suppose if you have tracked your own personal data and you know you have a low miss rate, then that’s great. But if you haven’t tracked your own data, the HEART and other scoring systems can be used to give you some real numbers.

      Back to the risk management issue, which is really the key to why I am talking about this stuff at lectures and on podcasts.
      Practically all lawsuits are based on clinical gestalt. If an internationally-known plaintiff expert comes in and says that he/she disagrees with your clinical gestalt, and your gestalt was clearly wrong and that’s why the patient is dead, you’ve got a problem. But by having a scoring system that has been prospectively, externally, internationally validated that says that what you did is reasonable, you are in good position to win the case…or not get sued in the first place.

      Almost all of the lawsuits I end up being asked to defend are patients that were deemed low-risk by the emergency physician based on gestalt. There are plenty of physicians out there whose gestalt is not working right. Many of these are not even questionable cases.

      If you work in a place where risk mgmt is not an issue, and you are pretty sure that your clinical gestalt is damn good, then you don’t need any of this stuff.

      This is primarily a risk mgmt issue.
      This is primarily a risk mgmt issue.
      This is primarily a risk mgmt issue.

      In terms of the outcome of low risk patients sent home, we know that if you use the ADP or the HEART score, the risk is very very low. But those are patients deemed “low risk” based on these scoring systems. I’m guessing the listener is asking the question about the risk of “low risk” patients being sent home if “low risk” was based on gestalt. I don’t know if there’s good data on that, largely because gestalt can vary quite a bit amongst providers.

  4. SK

    Thanks Rob and Amal.
    fantastic podcast.
    Despite all these years of experience i always found dealing with non specific chest pain very frustrating.
    This scoring system makes life so much easier if used properly.
    As Rich Levitan says this is the Ahaa moment- for chest pain patients.
    i think a scoring system like this for chest pain was long overdue.
    thanks once again.

  5. Axel Ellrodt

    Problem is there is some Gestalt in attributing 2, 1 or 0 to the history in the HEART score.

    I’ a bit puzzled that HEARt and other scores include traditional chronic risk factors for coronary disease, which ave been reported roughly useless (1,2), and yet , HEART performs well.

    In addition , one “high risk feature” in Heart that may be used to chose the HERAT history score, is “pain resolves with TNT. Hich I understand has been proven to be akin to fllipping a coin.

    History of atherosclerotic is another story and plays as a heavyweight in the score.

    What do you think about that discrepancy ?

    I’d be interested in your learned comments

    1- https://www.ncbi.nlm.nih.gov/pubmed/17145112
    2- https://www.ncbi.nlm.nih.gov/pubmed/18691797

    1. Post
      Author
      Rob Orman

      Hey Axel! As you say, the heavy weighting of risk factors seems to go against some previous literature. This is a confusing topic and one we’ll be addressing on an upcoming EM:RAP. I’ve heard the study authors speak to this point but don’t think I can do justice to the reasoning behind risk factors and trop having equal importance. Stay tuned.

  6. Luke

    I have seen it quoted several times that the repeat troponin reduces MACE to < 1%. However, I have not seen anyone cite a reference, and I did a literature search and could not find the article. Could you help me out by giving me the source of this article?

    1. Post
      Author

Awesome article, I know - please share your erudite thoughts...