IU Health Methodist Hospital

At The Methodist ER With Chest Pain? You’re Going To Get Scored

August 17, 2017

The first 10 minutes will never change. It doesn’t matter if you’re a 60-year-old, obese man who smokes two packs of cigarettes a day or a 35-year-old woman who runs marathons.

Walk into the emergency department at IU Health Methodist Hospital with chest pains and you’re going to immediately get an electrocardiogram (EKG).

But if that EKG doesn’t show a definite heart attack taking place that needs immediate treatment, then things will turn markedly different – depending on whether you are that obese smoker or that young marathoner.

Depending on a whole host of factors -- including how old you are, whether you have a parent or sibling who had cardiovascular disease before age 65, whether you have high cholesterol and what your EKG looked like -- you will be scored.

It’s all part of a new risk stratification called the HEART Score that evaluates patients with chest pain and their risk of an adverse cardiac event in the near future. It’s a strategy launched last month at Methodist that allows physicians and medical care teams to have a common language amongst them -- and a protocol for best treatment for each patient.

After all, for every person who comes into the ER with chest pain who is having a heart attack, dozens of patients come in with chest pain who aren’t, says Richard Kovacs, M.D., an IU Health cardiologist and vice president-elect of the American College of Cardiology.

In fact, chest pain accounts for more than 8 million emergency department visits in the United States. But more than 90 percent of those patients aren’t actually having a heart attack.

Now, rather than treating everyone who complains of chest pain in the same way, Methodist is taking a customized approach.

The decision to use the HEART Score was born out of a joint effort between Methodist’s cardiology and emergency departments to treat patients with chest pain, Dr. Kovacs says.

“We are now collaborating on consistent protocol to manage those patients,” Dr. Kovacs says. “To take care of those patients the best we know how and do it expeditiously and accurately and improve communication.”

With the HEART Score, patients are evaluated and given a score of 0 to 10.

“It helps us assess the risk of those patients in a consistent way, in a way that can be communicated from provider to provider seamlessly,” Dr. Kovacs says. “We are all speaking the same language.”

How The HEART Score Works

The “H” stands for history: Patients are evaluated on whether they are slightly (0), moderately (+1) or highly (+2) suspicious for a possible cardiac event.

The “E” is for electrocardiogram: Is it normal (0), not specific (+1) or abnormal (+2)?

“A” represents age: Is the patient under 45 (0), 45 to 65 (+1) or older than 65 (+2).

The “R” stands for risk factors: No known risk factors (0), one to two risk factors (+1) or three or more risk factors (+2). Among risk factors scored is smoking, high cholesterol, a parent or sibling with cardiovascular disease before age 65 and more.

And the “T” is for troponin. Did the blood test show the normal limit (0), one to two times the normal limit (+1) or more than two times the normal limit (+2)?

“The total score added up puts people into one of three buckets,” Dr. Kovacs says.

Either they are low risk (score of 0-3), which means a 0.9 to 1.7 percent risk of an adverse cardiac event; intermediate risk (score of 4-6) with a 12 to 16.6 percent risk; or high risk (score of 7 or greater), which means a 50 to 65 percent risk of adverse cardiac event.

The team at IU Health then takes that HEART Score and determines how best to treat the patient.

For example, a person in the low risk category would most likely be treated as an outpatient. Someone in the intermediate bucket would go to the emergency department’s IDTU, for more testing.

And those with a HEART Score categorizing them high risk “are largely admitted and managed, often with a heart catheterization,” Dr. Kovacs says.

The new risk stratification might allow someone with a HEART Score of 0 to possibly go home when, before, they could have been asked to stay for six or eight or 12 hours for another blood test or EKG. They might have been held overnight to have a stress test in the morning.

“Some might have been admitted unnecessarily because of uncertainty about what to do,” Dr. Kovacs says. “We are now reducing the variation and practicing much better and more consistent care.”

-- By Dana Benbow, Senior Journalist at IU Health.

Reach Benbow via email dbenbow@iuhealth.org or on Twitter @danabenbow.

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