Cardiology, Improving Outcomes, Improving Throughput

A chicken in every pot, and a cardiologist in every box.

I think the HEART score is useful, and an incredible start to getting everyone on the same page. Getting both an ED and consultant group to universally agree on a protocol, and implement observation / admission protocols off of it are probably a bit more difficult.

And this is only with a few “soft” variables– what exactly differentiates slightly from moderately suspicious anyway? As we all know, stories change (and not just from patients!).

This paper retrospectively looked at 6 months worth of ED chest pain charts which had a cardiology consult and tries to extract a HEART score based off the ED documentation as well as the cardiology consultation.

Unfortunately the retrospective nature and lack of a standardized “flow sheet” for history probably greatly contributes to cardiology/EP disagreement in the HEART score (like, say, documenting tobacco usage in the chart). History between EP and cardiology was in agreement 47% of the time, EKG interpretation agreement at 76%, and risk factor agreement at 85%. Overall HEART score agreement between EP’s and cardiology occurred 70% of the time, primarily with some mixture of cardiology consistently downplaying elements and/or EP’s upselling some.

Of those who had a phone consultation with cardiology, only 5.4% were discharged, vs 45% discharged when physically seen by cardiology. Only 9% were admitted after in-person cardiology evaluation vs 77% for those with phone consultation. Of those who received further testing, 45% of the cardiology phone consultations were discharged, vs 87% discharge rate for those who received additional testing after an in-person cardiology consultation…. Seems like cardiology is scared to discharge without seeing the patient, and that we are probably upselling the patient a bit.

Regardless, this is hypothesis generating at best, particularly with such low numbers to evaluate (33 patients evaluated by cardiology and EP’s over this 3 month period!), and frankly, the retrospective data extraction without a clear checklist for HEART scores makes me question the validity of their conclusions. Nonetheless, I hold hope that cardiology and EM can live in harmony at some point in the future.

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