57-year-old male, with controlled hypertension, presents to emergency department with a 2-hour history of a central, dull, chest pain that does not radiate.  He rates it as a 4/10 in severity and denies any aggravating or alleviating factors.  He reports some mild nausea and what he reports as “reflux” during this event as well.  He denies shortness of breath, vomiting, arm radiation, back radiation, abdominal pain, dizziness, or syncope.  His father has HTN, HLP, and had a non-fatal AMI at 62-years-old.  He is a never smoker.  His BMI is 27.3.

Vital signs show BP-122/82, HR-93, RR-16, O2-100% on room air, and temp-98.0.

Physical exam reveals:

HEENT – NC/AT

Skin – no diaphoresis

Cardiovascular – RRR without M/G/R

Pulmonary – CTA without adventitial breath sounds

Abdomen – S/ND, mild epigastric tenderness to deep palpation

Peripheral Vascular – 2+ pulses throughout

Neuro – A&Ox3, 5/5 strength throughout

EKG is below:

Laboratory Screening:

High-sensitivity troponin (hs-cTnI) – 0.02 ng/dL

CK-MB – 39 U/L

Total CK –  264 U/L

Myoglobin – 22 ng/mL

WHAT WOULD YOU DO NEXT???

Answer:

Discharge home with cardiovascular provocative testing as outpatient.

Why?  Low risk HEART score.  What is the HEART score?  Glad you asked.

The HEART score was first published in 2008 to evaluate occurrence of Major Adverse Cardiac Event (MACE) at 6 weeks.  MACE defined in the study was any occurrence of AMI, PCI, CABG, or death.  The 5 variables they used are:

R.E.B.E.L EM – A New ED Chest Pain Risk Stratification Score

The HEART score performed better than TIMI and GRACE predicting MACE in acute chest pain patients presenting to the ED.

For our patient, he has a HEART score of 3 (age + history + risk factors).  We could have a discussion with him regarding the risk of him having a MACE in the next 6 weeks and the risks/benefits of admission and testing now.  Below is a nice patient sheet that the University of Maryland (FEAR THE TURTLE) has developed to help with shared decision making in the ED.

University of Maryland. http://tinyurl.com/nc2k65n

References

1. Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Netherlands Heart Journal. 2008;16(6):191-6. [pubmed]
2. Backus BE, Six AJ, Kelder JC. A prospective validation of the HEART score for chest pain patients at the emergency department. International Journal of Cardiology. 2013;168(3):2153-8. [pubmed]
3. R.E.B.E.L. EM – A New ED Chest Pain Risk Stratification Score.  January 10, 2014. http://rebelem.com/heart-score-new-ed-chest-pain-risk-stratification-score/#ITEM-588-2