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Original Research
25 April 2017

Effect of Using the HEART Score in Patients With Chest Pain in the Emergency Department: A Stepped-Wedge, Cluster Randomized Trial

Authors: Judith M. Poldervaart, MD, PhD, Johannes B. Reitsma, MD, PhD, Barbra E. Backus, MD, PhD, Hendrik Koffijberg, PhD, Rolf F. Veldkamp, MD, PhD, Monique E. ten Haaf, MD, Yolande Appelman, MD, PhD, … Show All … , Herman F.J. Mannaerts, MD, PhD, Jan-Melle van Dantzig, MD, PhD, Madelon van den Heuvel, MD, Mohamed el Farissi, MD, Bernard J.W.M. Rensing, MD, PhD, Nicolette M.S.K.J. Ernst, MD, PhD, Ineke M.C. Dekker, MD, Frank R. den Hartog, MD, Thomas Oosterhof, MD, PhD, Ghizelda R. Lagerweij, Eugene M. Buijs, MD, PhD, Maarten W.J. van Hessen, MD, PhD, Marcel A.J. Landman, MD, Roland R.J. van Kimmenade, MD, PhD, Luc Cozijnsen, MD, Jeroen J.J. Bucx, MD, PhD, Clara E.E. van Ofwegen-Hanekamp, MD, PhD, Maarten-Jan Cramer, MD, PhD, A. Jacob Six, MD, PhD, Pieter A. Doevendans, MD, PhD, and Arno W. Hoes, MD, PhDAuthor, Article, & Disclosure Information
Publication: Annals of Internal Medicine
Volume 166, Number 10
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Abstract

This article has been corrected. The original version (PDF) is appended to this article as a Supplement.

Background:

The HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score is an easy-to-apply instrument to stratify patients with chest pain according to their short-term risk for major adverse cardiac events (MACEs), but its effect on daily practice is unknown.

Objective:

To measure the effect of use of the HEART score on patient outcomes and use of health care resources.

Design:

Stepped-wedge, cluster randomized trial. (ClinicalTrials.gov: NCT01756846)

Setting:

Emergency departments in 9 Dutch hospitals.

Patients:

Unselected patients with chest pain presenting at emergency departments in 2013 and 2014.

Intervention:

All hospitals started with usual care. Every 6 weeks, 1 hospital was randomly assigned to switch to “HEART care,” during which physicians calculated the HEART score to guide patient management.

Measurements:

For safety, a noninferiority margin of a 3.0% absolute increase in MACEs within 6 weeks was set. Other outcomes included use of health care resources, quality of life, and cost-effectiveness.

Results:

A total of 3648 patients were included (1827 receiving usual care and 1821 receiving HEART care). Six-week incidence of MACEs during HEART care was 1.3% lower than during usual care (upper limit of the 1-sided 95% CI, 2.1% [within the noninferiority margin of 3.0%]). In low-risk patients, incidence of MACEs was 2.0% (95% CI, 1.2% to 3.3%). No statistically significant differences in early discharge, readmissions, recurrent emergency department visits, outpatient visits, or visits to general practitioners were observed.

Limitation:

Physicians were hesitant to refrain from admission and diagnostic tests in patients classified as low risk by the HEART score.

Conclusion:

Using the HEART score during initial assessment of patients with chest pain is safe, but the effect on health care resources is limited, possibly due to nonadherence to management recommendations.

Primary Funding Source:

Netherlands Organisation for Health Research and Development.

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Supplemental Material

Supplement. Research Protocol

Supplement. Original Version (PDF)

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Judith Poldervaart, Hans Reitsma, Jacob Six, Rolf Veldkamp, Arno Hoes20 July 2017
Author's Response
We thank Moumneh and colleagues for their response on the results of the HEART-Impact trial. They suggest another possible explanation for the small impact on health care resources we observed, and relate this to the “troponin measurement for all patients with chest pain even for patients with a very low clinical probability of acute coronary syndrome”.
In the dataset of the HEART-Impact trial 136 of the 1766 patients (7.7%) had a HEART score of 0 (n=30) or 1 (n=106); none of these 136 patients had a positive troponin measurement, suggesting a small efficiency gain of these 8% of patients who possibly may be discharged very early from the emergency department, without a troponin measurement. Taking a two-step approach by only performing troponin testing in those that have a maximum total score of 1 on the other items (HEAR) of the HEART score might be more cost-effective, but this algorithm not assessed in our study. Our aim was to determine the value of the HEART score in daily practice.
We wish to stress once again the fact that the HEART score is a decision tool, and not a strict rule to adhere to, in all chest pain patients. For example, in patients with a very clear low probability, the physician may decide not to use the HEART score at all. What is crucial here is the suspicion of the physician: when one suspects a patient of a possible acute coronary syndrome, he or she can decide to calculate the HEART score. More importantly, in every patient with suspicion of acute coronary syndrome, the physician will want to perform a troponin measurement for understandable safety reasons, since this measurement is so sensitive for detecting myocardial damage.
Overall, the diagnostic dilemma of acute coronary syndrome is one of the balance between efficiency and safety, which is a discussion also to be held in a broader societal context. What risk do we find acceptable in chest pain patients, when also incorporating the risk of overtreatment?
The CARE score (taking a 2 step approach) the authors are currently testing seems very interesting and we are looking forward to the publication of their findings.
Thomas Moumneh, Delphine Douillet, Pierre-Marie Roy22 May 2017
Comments on Effect of Using the HEART Score in Patients With Chest Pain in the Emergency Department: A Stepped-Wedge Cluster Randomized Trial
To the editor: We found the study by Poldervaart et al. to be of great interest. They confirmed the safety of the HEART-score, proving non-inferiority versus usual care with a difference of -1.3% of MACE. Accordingly, chest pain patients with a score < 4 calculated on 5 criteria each quoted between 0 and 2, could safely be discharged early from the ED. However, even though their study suggests that the HEART-score implementation is cost-effective, they failed to show a significant difference in the use of health care resources, especially in the rate of patients discharged early and of those who spend an average length of time in the ED. The authors propose possible reasons for this discrepancy such as the lack of adherence of physicians on HEART-based recommendations because of safety concerns. We suspect another possible explanation. Indeed, the HEART-score includes a troponin measurement for all patients with chest pain even for patients with a very low clinical probability of acute coronary syndrome. For these patients, most troponin tests will be negative, leading to a significant waste of time. Performing a biological testing double emergency department length of stay(1). More importantly, applying Bayes theorem, positive results in patients with a low pre-test probability are at high risk of being false positive results(2,3). This notion is included in the HEART-score itself. Indeed, when the sum of the 4 clinical criteria of the score (without troponin) is 0 or 1, the highest overall HEART-score adding troponin is 3, meaning that the patient is always at low risk and eligible for early discharge. We defined the CARE-rule as “Characteristics of the pain, Age, Risk factors and Electrocardiogram”, deduced from the HEART-score criteria and likewise weighted. As the PERC-rule for pulmonary embolism(4), a CARE-score below 2 is supposed to exclude an acute coronary syndrome and allow early discharge without further testing. We evaluated the CARE-rule in a pilot prospective observational study (submitted). Among 641 patients who consulted the ED for non-traumatic chest pain, 31% had a negative CARE-rule. None of them experienced MACE during the 6-week follow-up. Moreover, 32% had a positive CARE-rule and a HEART-score ≤ 3 and none of them had a MACE. It can therefore be assumed that combining the CARE-rule and the HEART-score will decrease the use of health care resources, improving cost-effectiveness without compromising the safety of medical care of chest pain patients. We are still evaluating this hypothesis in a prospective multicentre study (ClinicalTrials.gov Identifier: NCT02813499).

1. Chaou C-H, Chen H-H, Chang S-H, et al. Predicting Length of Stay among Patients Discharged from the Emergency Department—Using an Accelerated Failure Time Model. PLOS ONE. 2017;12(1):e0165756. doi:10.1371/journal.pone.0165756.
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Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 166 • Number 10 • 16 May 2017
Pages: 689 - 697

History

Published online: 25 April 2017
Published in issue: 16 May 2017

Keywords

  1. Electrocardiography
  2. Emergency department
  3. Health care
  4. Heart
  5. Ischemia
  6. Medical risk factors
  7. Patients
  8. Quality of life
  9. Safety
  10. Troponin

Copyright

© 2017 American College of Physicians.

Authors

Affiliations

Judith M. Poldervaart, MD, PhD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Johannes B. Reitsma, MD, PhD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Barbra E. Backus, MD, PhD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Hendrik Koffijberg, PhD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Rolf F. Veldkamp, MD, PhD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Monique E. ten Haaf, MD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Yolande Appelman, MD, PhD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Herman F.J. Mannaerts, MD, PhD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Jan-Melle van Dantzig, MD, PhD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Madelon van den Heuvel, MD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Mohamed el Farissi, MD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Bernard J.W.M. Rensing, MD, PhD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Nicolette M.S.K.J. Ernst, MD, PhD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Ineke M.C. Dekker, MD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Frank R. den Hartog, MD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Thomas Oosterhof, MD, PhD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Ghizelda R. Lagerweij
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Eugene M. Buijs, MD, PhD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Maarten W.J. van Hessen, MD, PhD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Marcel A.J. Landman, MD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Roland R.J. van Kimmenade, MD, PhD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Luc Cozijnsen, MD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Jeroen J.J. Bucx, MD, PhD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Clara E.E. van Ofwegen-Hanekamp, MD, PhD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Maarten-Jan Cramer, MD, PhD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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A. Jacob Six, MD, PhD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Pieter A. Doevendans, MD, PhD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Arno W. Hoes, MD, PhD
From University Medical Center Utrecht and Diakonessenhuis Utrecht, Utrecht; University of Twente, Enschede; Medical Center The Hague, The Hague; Vu University Medical Center, Amsterdam; Amstelland Hospital, Amstelveen; Catharina Hospital, Eindhoven; St. Antonius Hospital, Nieuwegein; Zuyderland Hospital, Heerlen; Gelderse Vallei Hospital, Ede; Tergooi Hospital, Hilversum; Groene Hart Hospital, Gouda; Meander Medical Center, Amersfoort; Radboud University Medical Center, Nijmegen;
Maastricht University Medical Center, Maastricht; Gelre Hospital, Apeldoorn; and Zuwe Hofpoort Hospital, Woerden, the Netherlands.
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Acknowledgment: The authors thank all participating hospitals, especially all cardiac residents, nurses, secretaries, research and development departments, and local laboratories (Diagnostisch Laboratorium Saltro Utrecht, Atalmedial, MDC Amstelland, Trombosedienst Gelderse vallei Ede, Diagnostiek voor U, and the laboratory of Atrium Medical Center). They also thank their monitor, Gerda Kuiper; the Data Safety and Monitoring Board (Arend Mosterd, Kit Roes, Gert-Jan de Borst, Carla Bruijnzeel-Koomen, and Caroline van Baal); the data managers (Jildou Zwerver, Susan van Hemert, and Joost Schotsman); and the trial nurses (Lydeke Zwart, Carla Tims-Polderman, Els Kooiman, Boudewijn Uppelschoten, and Mieke de Haas) for their extensive help during data collection. Finally, the authors thank the members of their outcome committee for their precise adjudication, especially the extra members of the adjudication consensus committee (Adriaan van Kraaijeveld and Jeroen Smits).
Grant Support: A research grant was obtained from the Netherlands Organisation for Health Research and Development (ZorgOnderzoek Nederland en Medische wetenschappen [ZonMw]) (grant project 171202015) as part of the Effectiveness Program (Doelmatigheidsprogramma ZonMw).
Disclosures: Prof. Hoes reports that he chairs a large research and teaching institute within University Medical Center Utrecht that performs investigator- and industry-driven research projects with numerous pharmaceutical and diagnostic companies. In addition, some staff members receive unrestricted grants for research projects from a number of companies. It is the explicit policy of the institute to work with several companies and not focus on 1 or 2 industrial partners. Prof. Hoes receives no personal payment from any industrial partner. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1600.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement: Study protocol: The published protocol is available at www.ncbi.nlm.nih.gov/pubmed/24070098. The protocol for the institutional review board is available in the Supplement. Statistical code: Available from Dr. Poldervaart (e-mail, [email protected]). Data set: Not available.
Corresponding Author: Judith M. Poldervaart, MD, PhD, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Straat 6.101, PO Box 85500, 3508 AB Utrecht, the Netherlands; e-mail, [email protected].
Current Author Addresses: Drs. Poldervaart, Reitsma, and Koffijberg; Ms. Lagerweij; and Prof. Hoes: Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Straat 6.101, PO Box 85500, 3508 AB Utrecht, the Netherlands.
Dr. Backus: Department of Emergency Medicine, Haaglanden Medical Center, Lijnbaan 32, 2512 VA The Hague, the Netherlands.
Dr. Veldkamp: Department of Cardiology, Haaglanden Medical Center, Lijnbaan 32, 2512 VA The Hague, the Netherlands.
Drs. ten Haaf and Appelman: Department of Cardiology, Vu University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands.
Dr. Mannaerts: Department of Cardiology, Amstelland Hospital, Amstelveen, the Netherlands.
Drs. van Dantzig, van den Heuvel, and el Farissi: Department of Cardiology, Catharina Hospital, Michelangelolaan 9, 5623 AZ Eindhoven, the Netherlands.
Dr. Rensing: Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands.
Drs. Ernst and Dekker: Department of Cardiology, Zuyderland Hospital, Heerlen, the Netherlands.
Drs. den Hartog and Oosterhof: Department of Cardiology, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP Ede, the Netherlands.
Dr. Buijs: Department of Cardiology, Tergooi Hospital, Rijksstraatweg 1, 1261 AN Hilversum, the Netherlands.
Dr. van Hessen: Department of Cardiology, Groene Hart Hospital, Bleuland Weg 10, 2803 HH Gouda, the Netherlands.
Dr. Landman: Department of Cardiology, Meander Medical Center, Maatweg 3, 3813 TZ Amersfoort, the Netherlands.
Dr. van Kimmenade: Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, the Netherlands.
Dr. Cozijnsen: Department of Cardiology, Gelre Hospital, PO Box 9014, 7300 DS Apeldoorn, the Netherlands.
Drs. Bucx and van Ofwegen-Hanekamp: Department of Cardiology, Diakonessenhuis Utrecht, Bosboomstraat 1, 3582 KE Utrecht, the Netherlands.
Dr. Cramer and Prof. Doevendans: Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA Utrecht, the Netherlands.
Dr. Six: Department of Cardiology, Zuwe Hofpoort Hospital, Sterrenburg 1, 3447 GN Woerden, the Netherlands.
Author Contributions: Conception and design: J.M. Poldervaart, J.B. Reitsma, A.J. Six, P.A. Doevendans, A.W. Hoes.
Analysis and interpretation of the data: J.M. Poldervaart, J.B. Reitsma, H. Koffijberg, G.R. Lagerweij, E.M. Buijs, A.J. Six.
Drafting of the article: J.M. Poldervaart, J.B. Reitsma, A.J. Six, A.W. Hoes.
Critical revision of the article for important intellectual content: J.M. Poldervaart, J.B. Reitsma, B.E. Backus, H. Koffijberg, R.F. Veldkamp, M.E. ten Haaf, Y. Appelman, E.M. Buijs, A.J. Six, P.A. Doevendans, A.W. Hoes.
Final approval of the article: J.M. Poldervaart, J.B. Reitsma, B.E. Backus, H. Koffijberg, R.F. Veldkamp, M.E. ten Haaf, Y. Appelman, H.F.J. Mannaerts, J.M. van Dantzig, M. van den Heuvel, M. el Farissi, B.J.W.M. Rensing, N.M.S.K.J. Ernst, I.M.C. Dekker, F.R. den Hartog, T. Oosterhof, G.R. Lagerweij, E.M. Buijs, M.W.J. van Hessen, M.A.J. Landman, R.R.J. van Kimmenade, L. Cozijnsen, J.J.J. Bucx, C.E.E. van Ofwegen-Hanekamp, M.J. Cramer, A.J. Six, P.A. Doevendans, A.W. Hoes.
Provision of study materials or patients: J.M. Poldervaart, R.F. Veldkamp, M.E. ten Haaf, Y. Appelman, J.M. van Dantzig, N.M.S.K.J. Ernst, F.R. den Hartog, T. Oosterhof, J.J.J. Bucx, C.E.E. van Ofwegen-Hanekamp, A.J. Six.
Statistical expertise: J.M. Poldervaart, J.B. Reitsma, H. Koffijberg, G.R. Lagerweij.
Obtaining of funding: B.E. Backus, A.J. Six.
Administrative, technical, or logistic support: J.M. Poldervaart, B.E. Backus, R.F. Veldkamp, M.E. ten Haaf, J.M. van Dantzig, M. van den Heuvel, M. el Farissi, I.M.C. Dekker, E.M. Buijs, R.R.J. van Kimmenade, L. Cozijnsen, J.J.J. Bucx, C.E.E. van Ofwegen-Hanekamp, A.J. Six.
Collection and assembly of data: J.M. Poldervaart, R.F. Veldkamp, M.E. ten Haaf, H.F.J. Mannaerts, J.M. van Dantzig, M. van den Heuvel, M. el Farissi, B.J.W.M. Rensing, N.M.S.K.J. Ernst, I.M.C. Dekker, T. Oosterhof, E.M. Buijs, M.A.J. Landman, M.J. Cramer, A.J. Six.
This article was published at Annals.org on 25 April 2017.

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Judith M. Poldervaart, Johannes B. Reitsma, Barbra E. Backus, et al. Effect of Using the HEART Score in Patients With Chest Pain in the Emergency Department: A Stepped-Wedge, Cluster Randomized Trial. Ann Intern Med.2017;166:689-697. [Epub 25 April 2017]. doi:10.7326/M16-1600

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