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Hesitancy to Use HEART Score Keeps Emergency Care Costs High

UTRECHT, THE NETHERLANDS – Emergency physicians often remain wary about using a common algorithm to determine whether chest pain patients need to be admitted, observed, or discharged.

That’s according to a new report in the Annals of Internal Medicine, which discusses why the availability of the HEART (History, ECG, Age, Risk factors, and initial Troponin) score might have little effect on healthcare costs.

A study team led by University Medical Center in Utrecht researchers points out that for the great majority, 80%, of patients presenting to the ED with chest pain, the cause is a non-cardiac condition. Yet, the article adds, in many countries with advanced healthcare systems, two-thirds of patients are admitted and undergo further evaluation.

The researchers emphasize that a risk stratification tool such as HEART could make a difference, but its safety in real-world emergency medicine hasn’t been fully established.

To provide more information, the study team focused on chest pain patients at EDs in nine Dutch medical centers in 2013 and 2014. The stepped-wedge, cluster randomized trial design, which they employed, meant that all hospitals began providing usual care but, every six weeks, one of them was chosen to switch to care using the HEART score.

Ultimately, 3,648 patients were included in the analysis, divided almost equally between usual care and HEART-influenced care.


After six weeks, participants in the HEART care group had a 1.3% lower rate of major adverse cardiac events than those in usual care. No statistically significant differences were detected in a number of measures, including early discharge, readmissions, recurrent ED visits, outpatient visits, or visits to general practitioners.

The researchers report that, while healthcare resource usage was usually lower in patients receiving care based on the HEART score, those differences didn’t reach statistically significant levels. Yet, extrapolation of the findings suggests that HEART care could lead to annual savings of €40 million in the Netherlands if used consistently.

A key issue, according to study authors, is that “physicians were hesitant to refrain from admission and diagnostic tests in patients classified as low risk by the HEART score.”

“Using the HEART score during initial assessment of patients with chest pain is safe, but the effect on health care resources is limited, possibly due to nonadherence to management recommendations,” they conclude.