Clinically relevant adverse cardiovascular events in intermediate heart score patients admitted to the hospital following a negative emergency department evaluation

Am J Emerg Med. 2021 Aug:46:469-475. doi: 10.1016/j.ajem.2020.10.065. Epub 2020 Nov 3.


Study hypothesis: Study objective: To estimate the frequency of clinically relevant adverse cardiac events (CRACE) in patients admitted to the hospital for chest pain with an intermediate HEART score (4, 5, 6), non-diagnostic EKG, and a negative initial troponin.

Methods: We conducted a retrospective analysis of all patients admitted to the University of Maryland Medical Center (UMMC) from May 2016 to May 2019 with an intermediate HEART score (4, 5, or 6), a non-diagnostic EKG, and a negative initial troponin. Our primary outcome was the rate of inpatient clinically relevant adverse cardiac events (CRACE), composite of life-threatening dysrhythmia, inpatient STEMI, cardiac or respiratory arrest, and all-cause mortality during hospitalization.

Results: A total of 1118 patients met our inclusion criteria, 6 of whom had CRACE. Overall the rate of CRACE was 0.5% (95% CI, 0.2-1.2%). Six patients (0.5%, 95% CI, 0.2%-1.2%) experienced inpatient NSTEMIs, 212 patients (19%, 95% CI, 17-21%) underwent provocative testing during their inpatient stay, 5 patients received a stent or CABG, and 5 patients had false positive non-invasive testing and underwent a negative cardiac catheterization.

Conclusions: In this cohort of admitted patients with a documented intermediate-risk HEART score, nonischemic EKG, and negative initial troponin, the occurrence of CRACE during the index hospitalization was 0.5%.

Keywords: Acute coronary syndrome; The HEART score.

MeSH terms

  • Acute Coronary Syndrome / blood
  • Acute Coronary Syndrome / diagnosis*
  • Acute Coronary Syndrome / physiopathology
  • Aged
  • Arrhythmias, Cardiac / epidemiology*
  • Cardiac Catheterization / statistics & numerical data
  • Chest Pain*
  • Coronary Artery Bypass / statistics & numerical data
  • Decision Support Systems, Clinical
  • Electrocardiography*
  • Emergency Service, Hospital
  • Exercise Test
  • Female
  • Heart Arrest / epidemiology*
  • Hospital Mortality*
  • Hospitalization*
  • Humans
  • Male
  • Middle Aged
  • Non-ST Elevated Myocardial Infarction / epidemiology
  • Percutaneous Coronary Intervention / statistics & numerical data
  • Retrospective Studies
  • Risk Assessment
  • ST Elevation Myocardial Infarction / epidemiology*
  • Troponin I / blood*


  • TNNI3 protein, human
  • Troponin I