The Case

The patient is a 45 year old male with a history of hypertension and hyperlipidemia who presented to the emergency department for chest pain. He reports it started an hour prior to arrival. It radiates to his shoulder and worsens with movement and inspiration. He denies any history of cardiac disease. Denies any shortness of breath. Vitals are normal. Physical examination is notable for reproducibility of pain with movement of left arm.

EKG shows normal sinus rhythm without ST segment changes or T-wave inversions.

Clinical Questions

How can we risk stratify this patient for cardiac disease using the EDACS score?
What is the Benefit of using the EDACS score over the commonly used HEART score?

Background

Non-traumatic chest pain accounts for 5-20% of ED visits and is the second most common presentation to the ED [1]
25% of admissions are for chest pain [2]
Evaluation of chest pain costs ~10 billion dollars annually [3]
Only ~10% are diagnosed with ACS that would require hospitalization
Ideally ruling out low risk CP would reduced healthcare costs

Current Common Practice

HEART Score

Derived from a single center retrospective observational study Netherlands
96-98% sensitivity (including validation)
Validated in New Zealand and 10 other centers in Netherlands [4]
32-36% were classified as low risk chest pain
- These patients were deemed safe for discharge
0.99-2.5% risk of MACE (Major Adverse Cardiovascular Event) at 30 days
Risk reduced to less than 1% with a negative delta troponin at hour 3

Benefits of the HEART Score

Easy to use
Good sensitivity
Low risk of MACE
Allows us to discharge low risk chest pain with a well validated score

Pitfalls of the HEART Score

High inter-rater variability [5]
Subjective interpretations particularly in the History and EKG category
Arbitrary scoring system
Created for simplicity
Certain risk factors have higher pre-test probability

Emergency Department Assessment of Chest pain (EDACS)

EDACS Score – Why?

Rule out ACS in more patients than the HEART score
Excellent safety profile

EDACS Derivation Study

Developed 2014 by Than et. al [2]
Prospective observational study of patients from 2010-2011
Primary outcome: measurement of MACE at 30d
Identified variables with high statistical significance (p<0.05) assigned with a coefficient based on its predictive value
Modified for sensibility (Ease of use)
Externally validated with another institution in Australia
Sensitivity of 99%, specificity of ~50%
More than 50% discharged as low risk
Low risk of MACE (0-0.36%)

How to use it:

Calculate the score using signs and symptoms
Low risk if:
- EDACS< 16
- No new ischemia on EKG
- Hour t0 and t2 both troponin are negative
Low risk patients are safe for discharge

Pitfalls of EDACS Score

Not as easy to use or remember as compared to the HEART score

Comparison Trial·[8]

Results

Authors conclusions:

Both the HEART and EDACS score predicted low risk patients with a negative predictive value (NPV) >99%
EDACS rules out more low risk patients, and thus the preferred score

Summary Figure

Back to the Case

The patient is a 45 year old male with a history of hypertension and hyperlipidemia who presents to the emergency department of chest pain. He reports it started an hour prior to arrival. It radiates to his shoulder. Worsens with movement. He denies any history of cardiac disease. Denies any shortness of breath. Vitals are normal. Physical examination is notable for reproducibility of pain with movement of left arm. EKG is normal sinus rhythm without ST segment changes or T-wave inversions.

Score 3 (Low Risk)
- Safe for discharge with appropriate follow up

Summary

The HEART score is an excellent tool to rule out low risk chest pain
With the HEART score, you can discharge ~32-36% of patients
The EDACS score is a useful tool to help discharge >50% of patients
EDACS has an excellent safety profile
May be the future leading clinical decision tool in ruling out low risk CP

POST BY: DR. RAY JABOLA (R3)

References

Leite L, Baptista R, Leitao J, Cochicho J, Breda F, Elvas Luis, et al. Chest pain in the emergency department: risk stratification with Manchester triage system and HEART score. BMC Cardiovasc Disord. 2015; 15: 48.
Than M, Flaws D, Sanders S, Doust J, Glasziou P, Kline J, et al. Development and validation of the Emergency Department Assessment of Chest pain Score and 2 h accelerated diagnostic protocol. Emerg Med Australasa. 2014; 26(1): 34-44.
Riley RF, Miller CD, Russell GB, Harper EN, Hiestand BC, Hoekstra JW, et al. Cost Analysis of the HEART Pathway Randomized Control Trial. Am J Emerg Med. 2017 ; 35(1): 77–81.
Sharp AL, Wu YL, Shen E, Redberg R, Lee M, Ferenci M, et al. Prospective validation of HEART score for the prediction of 30-day death or myocardial infarction in community ED patients with possible acute coronary syndrome. Eur Heart J. 2018; 39(1): ehy565.1090.
Gershon CA, Yagapon AN, Lin A, Yanez D, Sun BC. Inter-rater Reliability of the HEART Score. Acad Emerg Med. 2019; 26(5): 552-555.
Flaws D, Than M, Scheuermeyer FX, Christenson J, Boychuk B, Greenslade JH, et al. External validation of the emergency department assessment of chest pain score accelerated diagnostic pathway (EDACS-ADP). Emerg Med J. 33:9.
Mark DG, Huang J, Chettipally U, Kene MV, Anderon ML, Hess EP. Performance of Coronary Risk Scores Among Patients With Chest Pain in the Emergency Department. J Am Coll Cardiol. 2018; 71 (6) 606–616
Lee H. CALC Corner: HEART Score vs. EDACS. EP Monthly. 2018. Accessed June 2022. <https://epmonthly.com/article/calc-corner-heart-score-vs-edacs/>
Body R, Morris N, Reynard C, Collinson PO. Comparison of four decision aids for the early diagnosis of acute coronary syndromes in the emergency department. Emerg Med J. 2019; 37(1).

EBM: Chest Pain Management in the ED – EDACS Score