Comparative evaluation of the ability to detect major cardiac events with the modified cocaine history, electrocardiogram, age, risk factors and troponin (HEART) score, HEART pathway and original HEART score in patients with cocaine-associated chest pain presenting at the emergency department.

Abstract

Introduction: This study primarily aimed to assess the ability to detect major cardiac events using the history, electrocardiogram, age, risk factors and troponin (HEART) pathway, modified cocaine HEART score, and HEART score among patients with cocaine-associated chest pain.

Methods: This single-centre retrospective study included consecutive patients with cocaine-associated chest pain admitted between January 2016 and December 2022 who were age and sex-matched in a 1:2 ratio to patients with chest pain not associated with cocaine use. The primary outcome was the percentage of major adverse cardiovascular events within 30 days.

Results: In total, 1,412 patients were included, with 1,653 presentations, of whom 551 presented with cocaine-associated chest pain and were ≥18 years old. Most presentations involved male patients (84%). Major adverse cardiovascular events occurred in 139 presentations: 50 (9.1%) among patients with cocaine-associated chest pain and 89 (8.1%) among patients with non-cocaine-associated chest pain. The number of low-risk presentations of cocaine-associated chest pain patients was 409 (74.2%), 345 (62.6%) and 394 (71.5%) according to the HEART score, modified cocaine HEART score and HEART pathway, respectively. The HEART pathway had the lowest percentage of observed major adverse cardiac events in low-risk patients (0%; 95% CI: 0-0.9%), followed by the modified cocaine HEART score (0.3%; 95% CI: 0.007-1.6%) and the HEART score (0.7%; 95% CI: 0.2-2.1%). Sensitivity, negative predictive value, and area under the curves were very similar between the three scores.

Discussion: The occurrence of missed major adverse cardiovascular events in low-risk patients was below 0.7% (95% CI: 0.2%-2.1%) in all three risk stratification scores. The HEART pathway was the safest risk stratification tool with a sensitivity and negative predictive value of 100%. Nevertheless the differences with the other risk stratification scores were non-significant.

Conclusions: All three risk stratification scores performed well in a low-risk population with cocaine-associated chest pain, with a percentage of 0.7% of patients with a missed major adverse cardiovascular event.