Chest pain in ED and common chest pain scores

Chest pain is one of the most common and challenging complaints encountered in the emergency department. It is a symptom that can be associated with a wide spectrum of conditions, ranging from benign to life-threatening disorders. Accurate and timely assessment is crucial to identify patients at risk for serious conditions such as acute coronary syndrome (ACS) and pulmonary embolism (PE) while avoiding unnecessary tests and hospital admissions for low-risk individuals. To enhance diagnostic precision and decision-making in cases of chest pain, emergency physicians frequently employ clinical scoring systems such as the HEART score, the Wells score, and the Pulmonary Embolism Rule-out Criteria (PERC) rule. These tools help to stratify risk, guide management, and ensure that patients receive appropriate care.

The HEART Score

The HEART score is a widely used clinical tool designed to assess the risk of major adverse cardiac events (MACE) in patients presenting with chest pain. The acronym "HEART" stands for History, Electrocardiogram (ECG), Age, Risk factors, and Troponin. Each component is scored from 0 to 2, for a maximum total of 10 points. 

1. History: The clinical history is categorized based on the likelihood of ACS.
2. Electrocardiogram: Findings such as ST-segment deviation are considered.
3. Age: Patients are scored based on their age brackets.
4. Risk factors: Common cardiovascular risk factors (e.g., hypertension, hyperlipidemia) are evaluated.
5. Troponin: Cardiac troponin levels are measured to assess myocardial injury.

A HEART score of 0-3 indicates low risk, 4-6 intermediate risk, and 7-10 high risk for MACE. Studies have shown that patients with a low HEART score can often be safely discharged with outpatient follow-up, while those with higher scores may require inpatient evaluation and advanced cardiac care. This tool has demonstrated efficacy in reducing unnecessary admissions and providing a structured approach to chest pain evaluation in the ED.

The Wells Score

The Wells score is a clinical prediction rule used to assess the probability of PE in patients. It is based on a combination of clinical criteria, including:

1. Clinical signs and symptoms of deep vein thrombosis (DVT).
2. PE as the most likely diagnosis.
3. Heart rate greater than 100 beats per minute.
4. Immobilization or surgery in the previous four weeks.
5. Previous DVT or PE.
6. Hemoptysis.
7. Malignancy.

Scores are summed to yield a total score, which stratifies patients into low, moderate, or high probability of PE. Wells score interpretation typically follows these ranges:
- Score <2: Low probability of PE (PE is unlikely).
- Score 2-6: Moderate probability of PE (consider D-dimer testing or imaging).
- Score >6: High probability of PE (consider immediate imaging).

The use of the Wells score allows clinicians to identify patients who may benefit from further diagnostic testing, such as D-dimer assay or computed tomography pulmonary angiography (CTPA), while avoiding extensive work-ups in low-risk patients.

The PERC Rule

The Pulmonary Embolism Rule-out Criteria (PERC) rule is another essential tool specifically designed to identify patients with a very low risk of PE who might safely avoid further diagnostic testing. It includes eight criteria:

1. Age less than 50 years.
2. Heart rate less than 100 beats per minute.
3. Oxygen saturation on room air ≥95%.
4. No hemoptysis.
5. No recent surgery or trauma (within four weeks).
6. No history of DVT or PE.
7. No unilateral leg swelling.
8. No estrogen use.

If a patient meets all PERC criteria and has a low pretest probability of PE based on clinical assessment, PE can effectively be ruled out without further testing. This approach helps minimise unnecessary radiation exposure and resource utilisation in the ED.

In conclusion, the use of clinical scoring systems such as the HEART score, Wells score, and PERC rule plays a pivotal role in the assessment and management of chest pain in the emergency department. These tools enable emergency physicians to stratify risk effectively, prioritise diagnostic tests, and make informed decisions about patient care pathways. By integrating these scores into clinical practice, healthcare providers can enhance the accuracy of diagnoses, improve patient outcomes, and optimise the use of healthcare resources.