Computerized history taking improves HEART score determination in acute chest pain patients
Authors: Brandberg H , Spaak J , Sundberg CJ , Koch S , Zakim D , Kahan T 
Published: May 2022

Abstract

Funding Acknowledgements
Type of funding sources: Foundation. Main funding source(s): Robert Bosch Stiftung (Stuttgart, Germany)
Region Stockholm (ALF project; Stockholm, Sweden)

Introduction
Chest pain is a common chief complaint in emergency departments (EDs). The Acute Cardiovascular Care Association recommends the use of History, ECG, Age, Risk factors, and Troponin (HEART) score for risk stratification. In hectic and overcrowded EDs computerized history taking (CHT) is one structured way for collecting the components of HEART score, which include medical history (H- and R-variables).

Purpose
To determine the proportion of acute chest pain patients where CHT can be used to calculate HEART score, and what interrater reliability the included variables have with physician acquired medical history.

Methods
Prospective cohort study with acute chest pain patients self-reporting medical histories using a CHT program (Clinical Expert Operating System, CLEOS) on a tablet. CLEOS, with &gt;17,000 decision nodes, mimics a physician interview and tailors each interview continuously depending on previous answers. Clinically stable women and men aged &gt;18 years with a chief complaint of chest pain and non-diagnostic ECG or serum markers for acute coronary syndrome were enrolled. Patients unable to carry out a CHT interview (e.g., severe impaired vision or confusion) were excluded. As recommended in regional guidelines a modified HEART score using the traditional classification of anginal symptoms, i.e. 1) central chest pain, 2) provoked by physical exertion and/or emotional stress, and 3) relieved by rest and/or nitrates, and traditional risk factors was used (see Table 1). Observations to each discrete H- and R-variable and medical history data were extracted from electronic health records (EHR) and the CHT database by the research staff. Cohen’s kappa statistics and interpretation according to Landis & Koch was used to describe the interrater reliability.

Results
A total of 1,000 consecutive patients were enrolled in one tertiary university hospital ED during 2017–2019 (mean age 55±17 years; 54% women), comparable to the general chest pain population (mean age 58±19 years; 50% women). A complete HEART score could be calculated in 60% of patients (H-variable 91%; R-variable 60%). Registered observations from EHR and CHT and interrater reliability data are presented in Table 1. Interrater reliability for the H-variable (classical anginal symptoms) was slight to moderate (kappa 0.19-0.44) and the R-variable (traditional risk factors) was moderate to almost perfect (kappa 0.56-0.88).

Conclusions
HEART score could be calculated in a majority of acute chest pain patients by the use of CHT. Interrater reliability was high for traditional risk factors but low to moderate for classical anginal symptoms. Our ongoing studies assess whether CHT combined with a risk score such as HEART score in an acute setting can be useful for improved risk stratification and, more important, to improve clinical outcomes.