ArticleBMC emergency medicine2026
Time-stratified HEART score discrimination and calibration in emergency chest pain: a retrospective cohort study.
Article in BMC emergency medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
aimsWe 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.
methodsA 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.
results30-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).
conclusionThe 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.
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