The following is a summary of “Assessing risk of major adverse cardiac events among patients with chest pain and cocaine use using the HEART score,” published in the June 2024 issue of Emergency Medicine by Murali, et al.

Chest pain (CP) is a frequent reason for emergency department (ED) visits and demands prompt evaluation to rule out acute coronary syndrome (ACS), which carries significant morbidity and mortality if missed. The HEART (History, Electrocardiogram, Age, Risk Factors, Troponin) score is a validated tool for risk stratification of patients at high risk for ACS and major adverse cardiac events (MACE). However, controversy surrounds the inclusion of cocaine use as a risk factor in the HEART score. For a study, researchers hypothesized that patients who are cocaine-positive (COP) would not exhibit a higher risk of 30-day MACE compared to patients who are cocaine-negative (CON).

The retrospective study included adult patients presenting to 13 EDs within a University’s Medical System from August 7, 2017, to August 19, 2021. Eligible patients had CP, underwent urine toxicology testing, and had their HEART scores prospectively calculated as part of their clinical evaluation. Areas Under The Receiver Operating Curve (AUROC) were calculated to assess the performance of the HEART score in predicting 30-day MACE for each group.

A total of 46,210 patient charts were analyzed, of which 663 (1.4%) were patients with COP. While mean age did not differ significantly between groups, fewer females were in the COP group (26.2% vs. 53.2%, P < 0.001). Mean HEART scores were 3.7 (±1.4) for patients with COP compared to 3.1 (±1.8, P < 0.001) for patients with CON. Although a higher proportion of COP patients had moderate HEART scores (54% with scores of 4–6) compared to patients with CON (35.2%, P < 0.001), the rates of 30-day MACE were similar in both groups at 1.1%. The AUROC for the HEART score was 0.72 for patients with COP and 0.78 for patients with CON. Specifically, the AUROC for the Risk Factor component of the HEART score, including cocaine use, was poor (0.54).

The study utilizing prospectively calculated HEART scores found that overall, the HEART score performed reasonably well in predicting 30-day MACE. Importantly, the presence of cocaine use as a risk factor did not correlate with increased risk of 30-day MACE in this cohort. Therefore, they recommended that clinicians continue to use the HEART score for risk stratification in patients presenting with chest pain, including those with a history of cocaine use.

Reference: sciencedirect.com/science/article/abs/pii/S0735675724000561