In our paper, we found that compared with heart score, new modified HEART score is superior to HEART score in the evaluation of fatal chest pain. The area under ROC curve of new modified HEART score were 0.975 (95%CI 0.964–0.987, p < 0.001), the best cut-off point was 5 scores, sensitivity and specificity were 90.7% and 93.3%. According to the risk factors and prognosis, acute non traumatic chest pain can be divided into ACS, fatal non myocardial ischemic chest pain (PE, AAD, acute tension pneumothorax) and other chest pain (gastroesophageal reflux, costochondritis, herpes zoster, etc.). There are some problems in the clinical diagnosis and treatment of acute chest pain in China. Firstly, the differential diagnosis of acute nontraumatic chest pain lacks standardized process. Secondly, patients with ACS have over treatment or insufficient treatment. Finally, unable to quickly identify high-risk and low-risk chest pain, patients stay in the emergency department for a long time. It is difficult for emergency physicians to immediately determine the cause of acute non traumatic chest pain. It is important to carry out early diagnosis, differential diagnosis and risk stratification for patients with acute chest pain. How to quickly identify the cause of acute chest pain and reduce high-risk mortality of chest pain patients have become the focus of our attention.
In the emergency department, many risk scores are used to identify high-risk patients with ACS and adverse events, so that patients can benefit from early treatment. Among them, TIMI risk score and GRACE risk score system are widely used. However, these scoring systems are all used in the evaluation of acute ischemic heart disease, and lack of evaluation function for chest pain caused by non myocardial ischemia. Up to 6.3% of emergency department patients are related to chest pain. And less than 25% will have an ACS of all chest pain patients. If patients at low risk for ACS could be recognized early in the diagnostic process, it has the potiential to reduce patient burden, length of stay at emergency department, frequency of hospitalization and costs. Therefore, some scholars have proposed the HEART score and HEARTs3 score to assess the risk of acute chest pain.
HEART score can be applied to patients with chest pain caused by non ischemic heart disease, however there are still deficiencies in the evaluation of patients with acute chest pain[14–16]. Firstly, the proportion of all kinds of scores is not weighted analysis, the elevation of troponin is equal to over 65 years old, which weakens the role of troponin in the diagnosis of myocardial infarction; Secondly, gender score is not included, and more and more studies have found that gender difference exists in patients with coronary heart disease; Thirdly, There was no dynamic monitoring of ECG and myocardial injury markers. The above shortcomings make the sensitivity of HEART score in identifying high-risk chest pain patients decreased and will bring adverse effects to clinical diagnosis and treatment. Fesmire M et al improved the HEART scoring system and proposed HEARTs3 scoring system, based on the HEART scoring system, three items including gender, electrocardiogram and troponin measured again after 2 hour. They compared 315 patients with ACS within 30 days and 1833 patients without ACS. The results showed that the ROC area was 0.985 vs. 0.825, P < 0.05, HEARTs3 score system greatly improved the ability to identify high-risk patients with chest pain. Although the HEARTs3 scoring system has strengthened the ability to identify chest pain in high-risk ACS, it also has some problems. At first, this score need to dynamically observe the cTnI index of electrocardiograph, it has relatively prolonged the diagnosis time of high-risk chest pain patients. Secondly, the diagnostic efficiency of PE, AAD and tension pneumothorax was not improved. Based on the above reasons, we propose to divide acute chest pain into two categories: non lethal chest pain and fatal chest pain according to the serious consequences of chest pain, and improve HEART score to quickly identify fatal chest pain and non fatal chest pain. The modified HEART score includes three items: cardiac function, hypertension and D-dimer. Through preliminary trials, we found that modified HEART score can effectively and quickly identify fatal chest pain patients, and provide a new diagnosis and treatment strategy for emergency department.
In the emergency department, there are still many difficulties in the differential diagnosis of chest pain, especially in patients with atypical ACS, acute aortic dissection and pulmonary embolism. Modified HEART score system does not put forward higher requirements for hospital experimental conditions, and its scoring items and data are easy to obtain, which is more suitable for extensive promotion in primary hospitals. It helps to promote the implementation of individualized treatment balance resource allocation to avoid high-risk patients unable to get timely treatment, or low-risk patients receiving over treatment and repeated examination, so as to save medical costs. Modified HEART score system can play a role in the rapid identification of high-risk fatal chest pain and exclusion of low-risk chest pain, which has great clinical application value.