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Aims <p>We compared HEART score discriminative performance and calibration for 30-day major adverse cardiac events (MACE) between off-hours and on-hours emergency department chest pain presentations.</p> Methods <p>A single-center retrospective cohort study was conducted at Istanbul Medipol Mega University Hospital from January 2020 through December 2025, enrolling 2,800 patients (off-hours <i>n</i> = 2,133; on-hours <i>n</i> = 667). Off-hours comprised evenings, nights, weekends, and public holidays. The primary outcome was 30-day MACE, defined as acute myocardial infarction, unplanned coronary revascularization, cardiac arrest, or all-cause death. Discrimination was compared by the DeLong method; an absolute between-group AUC difference below 0.08, set a priori, was used as the margin of clinical similarity. Calibration was assessed by the Hosmer-Lemeshow test, observed-to-expected ratio, and calibration slope.</p> Results <p>30-day MACE occurred in 14.4% of 2,800 patients. The HEART score AUC was 0.830 (95% CI 0.805–0.855) in off-hours and 0.821 (95% CI 0.778–0.865) in on-hours patients; ΔAUC was + 0.009 (95% CI -0.041 to + 0.058; <i>p</i> = 0.736), with the confidence interval contained within the a priori margin. At the rule-out threshold (HEART ≥ 4), off-hours sensitivity was 95.7% (95% CI 92.8–97.5%) and negative predictive value (NPV) was 97.7% (95% CI 96.2–98.7%). No differential shift effect was detected (interaction OR 1.039; 95% CI 0.867–1.247; <i>p</i> = 0.676). Both groups demonstrated systematic overestimation of absolute MACE risk relative to Backus 2013 probabilities (off-hours calibration intercept − 0.352; 95% CI -0.495 to -0.208; <i>p</i> &lt; 0.001), with no between-group difference (<i>p</i> = 0.998).</p> Conclusion <p>The HEART score showed clinically similar discrimination for 30-day MACE regardless of presentation time, supporting its use across different presentation times in tertiary-care settings with comparable infrastructure, pending prospective multicenter confirmation. Local recalibration of absolute risk estimates should be considered before probability-guided triage protocols are implemented in comparable settings.</p>

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Time-stratified HEART score discrimination and calibration in emergency chest pain: a retrospective cohort study

  • 期刊论文

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  • 发表日期：

    2026年6月17日

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  • Şebnem Zeynep Eke Kurt,
  • Uğur Durmuş,
  • Erdem Kurt,
  • Suphi Bahadırlı

摘要

Aims

We compared HEART score discriminative performance and calibration for 30-day major adverse cardiac events (MACE) between off-hours and on-hours emergency department chest pain presentations.

Methods

A single-center retrospective cohort study was conducted at Istanbul Medipol Mega University Hospital from January 2020 through December 2025, enrolling 2,800 patients (off-hours n = 2,133; on-hours n = 667). Off-hours comprised evenings, nights, weekends, and public holidays. The primary outcome was 30-day MACE, defined as acute myocardial infarction, unplanned coronary revascularization, cardiac arrest, or all-cause death. Discrimination was compared by the DeLong method; an absolute between-group AUC difference below 0.08, set a priori, was used as the margin of clinical similarity. Calibration was assessed by the Hosmer-Lemeshow test, observed-to-expected ratio, and calibration slope.

Results

30-day MACE occurred in 14.4% of 2,800 patients. The HEART score AUC was 0.830 (95% CI 0.805–0.855) in off-hours and 0.821 (95% CI 0.778–0.865) in on-hours patients; ΔAUC was + 0.009 (95% CI -0.041 to + 0.058; p = 0.736), with the confidence interval contained within the a priori margin. At the rule-out threshold (HEART ≥ 4), off-hours sensitivity was 95.7% (95% CI 92.8–97.5%) and negative predictive value (NPV) was 97.7% (95% CI 96.2–98.7%). No differential shift effect was detected (interaction OR 1.039; 95% CI 0.867–1.247; p = 0.676). Both groups demonstrated systematic overestimation of absolute MACE risk relative to Backus 2013 probabilities (off-hours calibration intercept − 0.352; 95% CI -0.495 to -0.208; p < 0.001), with no between-group difference (p = 0.998).

Conclusion

The HEART score showed clinically similar discrimination for 30-day MACE regardless of presentation time, supporting its use across different presentation times in tertiary-care settings with comparable infrastructure, pending prospective multicenter confirmation. Local recalibration of absolute risk estimates should be considered before probability-guided triage protocols are implemented in comparable settings.