Contributor: Taylor Lynch, MD
Educational Pearls:

How do we risk-stratify chest-pain patients?

• One option is the HEART score
  • This score predicts a patient’s 6-week risk of a major adverse cardiac event.
    • Ex. Cath procedure, CABG, PCI, death
• H stands for History
  • Ask 1) Was the patient diaphoretic? 2) Did they have nausea and/or vomiting? 3) Did the pain radiate down the right or left arm? 4) Was it exertional?
  • Yes to one = one point. Two or more = two points.
• E stands for EKG
  • One point for left ventricular hypertrophy, t-wave inversions, new bundle-branch blocks.
  • No points for first degree AV block, benign early repolarization, or QT-prolongation
  • Two points for ST-depression
• A stands for Age
  • >65 gets two points
  • 45-64 gets one point
• R stands for Risk factors
  • Hypertension, hyperlipidemia, diabetes, obesity, family history, smoking, previous MI, previous CABG, stroke, peripheral arterial disease
  • 1-2 risk factors get 1 point
  • More than two risk factors gets two points
• T stands for Troponin
  • 1-3x upper limit of normal gets one point
  • >3x upper limit of normal gets two points
• This gives you a score between zero and ten
  • 0-3 points, patients have a ~2% chance of an adverse event
    • These patients likely go home
  • 4-6 points, patients have a ~20% chance of an adverse event
    • These patients get admitted or expedited outpatient stress test/echo
  • 7-10 points, patients have a ~60% chance of an adverse event
    • Admit and call cardiology.
    • These patients likely get catheterized

References

1. Backus BE, Six AJ, Kelder JC, Bosschaert MA, Mast EG, Mosterd A, Veldkamp RF, Wardeh AJ, Tio R, Braam R, Monnink SH, van Tooren R, Mast TP, van den Akker F, Cramer MJ, Poldervaart JM, Hoes AW, Doevendans PA. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013 Oct 3;168(3):2153-8. doi: 10.1016/j.ijcard.2013.01.255. Epub 2013 Mar 7. PMID: 23465250.
2. Laureano-Phillips J, Robinson RD, Aryal S, Blair S, Wilson D, Boyd K, Schrader CD, Zenarosa NR, Wang H. HEART Score Risk Stratification of Low-Risk Chest Pain Patients in the Emergency Department: A Systematic Review and Meta-Analysis. Ann Emerg Med. 2019 Aug;74(2):187-203. doi: 10.1016/j.annemergmed.2018.12.010. Epub 2019 Feb 2. PMID: 30718010.
3. https://www.mdcalc.com/calc/1752/heart-score-major-cardiac-events

Summarized by Jeffrey Olson, MS4 | Edited by Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/

Contributor: Aaron Lessen, MD
Educational Pearls:

• A prospective study at the Mayo Clinic Rochester was conducted to examine whether patients actively using their phones on initial assessment in the ED was associated with higher discharge rates
• The study included 292 patients, and only about 15% of patients were on their phone
  • The patients on their phone tended to be a younger demographic
• Scribes were trained to record the data during their shifts
• The results did show that patients on their phone have a higher rate of discharge
  • 94% chance of discharge if the patient is on their phone
  • 64% chance of discharge if the patient is not on their phone
• This concept can potentially contribute to improving triage decisions

References

1. Garcia SI, Jacobson A, Moore GP, Frank J, Gifford W, Johnson S, Lazaro-Paulina D, Mullan A, Finch AS. Airway, breathing, cellphone: a new vital sign? Int J Emerg Med. 2024 Nov 22;17(1):177. doi: 10.1186/s12245-024-00769-0. PMID: 39578750; PMCID: PMC11583604.

Summarized by Meg Joyce, MS2 | Edited by Meg Joyce & Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/

Contributor: Travis Barlock MD
Educational Pearls

• Frank’s sign is a curious physical exam finding first described in the literature in 1973
  • Bilateral earlobe creases are recognized as a marker of coronary artery disease and cerebrovascular disease
• Some studies have found an increase in all-cause mortality in patients with bilateral diagonal earlobe creases
• The pathophysiology is still not fully understood
  • One 2020 study found histopathological changes associated with diagonal earlobe creases, potentially linking them via a model of hypoxia/reoxygenation

References

1. Elliott WJ, Karrison T. Increased all-cause and cardiac morbidity and mortality associated with the diagonal earlobe crease: a prospective cohort study. Am J Med. 1991;91(3):247-254. doi:10.1016/0002-9343(91)90123-f
2. Nazzal S, Hijazi B, Khalila L, Blum A. Diagonal Earlobe Crease (Frank's Sign): A Predictor of Cerebral Vascular Events. Am J Med. 2017;130(11):1324.e1-1324.e5. doi:10.1016/j.amjmed.2017.03.059
3. Stoyanov GS, Dzhenkov D, Petkova L, Sapundzhiev N, Georgiev S. The Histological Basis of Frank's Sign. Head Neck Pathol. 2021;15(2):402-407. doi:10.1007/s12105-020-01205-4

Summarized & Edited by Jorge Chalit, OMS4

Donate: https://emergencymedicalminute.org/donate/