HEART score, like TIMI and others, is a validated tool for risk stratifying patients. But they are different.
Table of Contents
Comparing HEART Score with TIMI
Many Emergency Medicine doctors prefer HEART score.
MDCalc.com says, “Newer chest pain risk scores such as the HEART Score have been shown to better stratify risk than the TIMI Score, particularly in the undifferentiated chest pain patient.” Click here and scroll to bullet point 3 under the advice section.
6-week vs. 2-weeks
The HEART score predicts the 6-week risk of a major adverse cardiac event (MACE). TIMI score only predicts a 2-week all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization.
Different Patient Populations, Different Purposes
The TIMI score was designed to identify high-risk patients, not intermediate or low-risk patients.
The TIMI studies were done in only ACS patients (UA/NSTEMI) patients. The article says, ” A total of 1957 patients with UA/NSTEMI were assigned to receive unfractionated heparin (test cohort) and 1953 to receive enoxaparin in TIMI 11B; 1564 and 1607 were assigned respectively in ESSENCE. The 3 validation cohorts were the unfractionated heparin group from ESSENCE and both enoxaparin groups.” JAMA. 2000 Aug 16;284(7):835-42
The conclusion of the abstract reads, “In patients with UA/NSTEMI, the TIMI risk score is a simple prognostication scheme that categorizes a patient’s risk of death and ischemic events and provides a basis for therapeutic decision making.” JAMA. 2000 Aug 16;284(7):835-42
The whole idea is that these patients already have to be diagnosed with NSTE-ACS, i.e. UA /NSTEMI. All these patients by today’s standards (and in the original studies) have to already be anticoagulated with heparin or enoxaparin.
The HEART score is different. It takes everybody who comes to the ER with chest pain and helps you risk stratify them to determine how to work them up.
1. Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Netherlands Heart Journal. 2008;16(6):191-196.
“In the literature, several risk scores for nSTE-ACS have been published. The most reputed are the TIMI, PURSUIT and GRACE risk scores, which were compared by De Araújo Gonçalves. Despite the firm scientific basis for all three scoring systems and the recommendations in guidelines, none is widely applied in clinical practice. These classical scoring systems do not show much interest in the differentiation of chest pain patients who are at low to moderate risk for an adverse outcome. The TIMI and PURSUIT scores were designed to identify high-risk patients, who are most likely to benefit from aggressive therapy. The major disadvantage of the GRACE score is that it can only be calculated with the use of the internet. The TIMI score is simple to calculate, but it is quite rough as it allows only binary choices, thus ignoring the fact that many variables have a ‘grey area’. The PURSUIT score is outdated as it was designed before the introduction of troponin assays for clinical use.”
2. Backus B., Six A., Kelder J., Gibler W., Moll F., Doevendans P. Risk Scores for Patients with Chest Pain: Evaluation in the Emergency Department. Current Cardiology Reviews. 2011;7(1):2-8. Curr Cardiol Rev. 2011 Feb; 7(1): 2–8
“The PURSUIT, TIMI, GRACE and FRISC risk scores are well validated with this respect. However, none of these risk scores has been used in the identification of an ACS in the emergency setting. The vast majority of patients with chest pain due to causes other than ACS were not evaluated in these trials. An evidence-based systematic stratification and policy for these patients does not currently exist.
The more recently developed HEART score is specifically designed to stratify all chest pain patients in the ED. The HEART score was validated in a retrospective multicenter study and proved to be a strong predictor of event-free survival on one hand and potentially life-threatening cardiac events on the other hand. The HEART score facilitates risk stratification of chest pain patients in the ED.” Curr Cardiol Rev. 2011 Feb; 7(1): 2–8.
3. Backus, B.E. et al. A prospective validation of the HEART score for chest pain patients at the emergency department. International Journal of Cardiology, Volume 168, Issue 3, 2153 – 2158. https://www.ncbi.nlm.nih.gov/pubmed/23465250
Free Article: http://www.internationaljournalofcardiology.com/article/S0167-5273(13)00315-X/fulltext
The TIMI score “is quite rough as it allows only binary choices, thus ignoring the fact that many variables have a ‘grey area'”
**Look at the TIMI score vs. the HEART score and see how true the critique of the TIMI score underlined above is. The TIMI score “is quite rough as it allows only binary choices, thus ignoring the fact that many variables have a ‘grey area'”
- TIMI score only considers age ≥ 65. If you are a 64-year-old male, you get zero points! Being 64 is not a risk factor, but being 65 and up is the only time it counts!
- TIM score only gives a point if you have ≥ 3 CAD risk factors. If you have 20 years of DM2 with A1C of 15 and severely uncontrolled HTN/HLD, you get zero points! Only 3 magically count.
- TIMI score requires “Severe angina (≥2 episodes in 24 hrs)” to give you one point. If you have only one classic angina episode (substernal, worse with exertion, relieved by rest) that is very severe, radiates to your LUE, neck, and jaw, and you felt like an elephant sitting on your chest, associated with shortness of breath. TIMI gives you zero points! It requires ≥2 episodes in 24 hrs! What if the patient came in immediately and didn’t wait to have the 2nd episode in the 23rd hour so that it becomes two episodes in 24 hours?
- TIMI score gives you one point for “Aspirin use in past 7 days.” Why? Is it b/c being on Aspirin and still having ACS means you are like someone who is having a clot while anticoagulated and that makes your situation complicated? I know ASA and anticoagulants for VTE are different. Just an example. Is it b/c patients on Aspirin are likely those who are at high risk of taking coronary atherosclerosis in the first place? Again, TIMI patients were all NSTE-ACS in the first place.
- TIMI only gives a point for “EKG ST changes ≥0.5mm”. It doesn’t give room for other things like LBBB, LVH, and repolarization changes in the absence of ST-segment changes. It doesn’t give a point even if you have T-wave inversions in contiguous leads.
- TIMI score gives one point for “Known CAD (stenosis ≥50%)”. This point is automatically not in contention for people who haven’t been cath before or done some study. Say two people come to the ER with the same CAD profile. One has been seen in the past and is known to have CAD(stenosis ≥50%). That person gets + 1 on TIMI. What if another person comes in who hasn’t ever been to the hospital before but also has unknown CAD(stenosis ≥65%)? That person gets zero points on TIMI score calculated at the time of admission or in the hospital before any invasive studies are done. Two people with the same CAD profile get two different scores simply because one is known and the other is unknown. Yet their risks are the same. We can’t say this of other risk factors like DM, HTN, HLD, etc. because we can find them out through history or through simple lab tests within a few hours of admission.
The following study externally validates previous findings that HEART
4. Six AJ1, Cullen L, Backus BE, Greenslade J, Parsonage W, Aldous S, Doevendans PA, Than M. The HEART score for the assessment of patients with chest pain in the emergency department: a multinational validation study. Crit Pathw Cardiol. 2013 Sep;12(3):121-6. https://www.ncbi.nlm.nih.gov/pubmed/23892941
Studies that show HEART Score is better than TIMI
Int J Cardiol. 2017 Jan 15;227:656-661. https://www.ncbi.nlm.nih.gov/pubmed/27810290
“Conclusion: The HEART score outperformed the GRACE and TIMI scores in discriminating between those with and without MACE in chest pain patients, and identified the largest group of low-risk patients at the same level of safety.”
Crit Pathw Cardiol. 2016 Mar;15(1):1-5. https://www.ncbi.nlm.nih.gov/pubmed/26881812
“The HEART score has better discrimination than TIMI and outperforms TIMI within previously published “low-risk” categories.”
HEART Score may save Money
http://bmjopen.bmj.com/content/6/6/e010694
HEART Score vs. HEART pathway
HEART Score for Major Cardiac Events.
Vs.
HEART Pathway for Early Discharge in Acute Chest Pain.
Original TIMI Article
JAMA. 2000 Aug 16;284(7):835-42. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. https://www.ncbi.nlm.nih.gov/pubmed/10938172.
https://jamanetwork.com/journals/jama/fullarticle/192996
Other good sources
http://rebelem.com/heart-score-new-ed-chest-pain-risk-stratification-score/