Background: The HEART Pathway is an accelerated diagnostic protocol (ADP) designed to identify low-risk Emergency Department (ED) patients with chest pain for early discharge without stress testing or angiography. The objective of this study was to determine whether implementation of the HEART Pathway is safe (30 day death and myocardial infarction rate <1% in low-risk patients) and effective (reduces 30 day hospitalizations) in ED patients with possible acute coronary syndrome (ACS). Methods: A prospective pre/post study was conducted at three US sites among 8,474 adult ED patients with possible ACS. Patients included were ≥21 years old, investigated for possible ACS, and had no evidence of ST-segment elevation myocardial infarction on electrocardiography. Accrual occurred for 12 months before and after HEART Pathway implementation from November 2013- January 2016. The HEART Pathway ADP was integrated into each site’s electronic health record as an interactive clinical decision support tool. Following ADP integration, ED providers prospectively utilized the HEART Pathway to identify patients with possible ACS as low-risk (appropriate for early discharge without stress testing or angiography) or non-low-risk (appropriate for further in-hospital evaluation). The primary safety and effectiveness outcomes, death and myocardial infarction (MI) and hospitalization rates at 30 days, were determined from health records, insurance claims, and death index data. Results: Pre- and post-implementation cohorts included 3713 and 4761 patients, respectively. The HEART Pathway identified 30.7% as low-risk; 0.4% of these patients experienced death or MI within 30 days. Hospitalization at 30 days was reduced by 6% in the post- vs pre-implementation cohort (55.6% vs 61.6%; aOR: 0.79, 95%CI: 0.71–0.87). During the index visit more MIs were detected in the post-implementation cohort (6.6% vs 5.7%; aOR: 1.36, 95%CI: 1.12–1.65). Rates of death or MI during follow-up were similar (1.1% vs 1.3%; aOR: 0.88, 95% CI: 0.58–1.33). Conclusions: HEART Pathway implementation was associated with decreased hospitalizations, increased identification of index visit MIs, and a very low death and MI rate among low-risk patients. These findings support use of the HEART Pathway to identify low-risk patients that can be safely discharged without stress testing or angiography. Clinical Trial Registration: clinicaltrials.gov Identifier: NCT02056964

Patients diagnosed with acute PE in U.S. EDs have high functional status, and their mortality rate is low. These registry data suggest that appropriate initial medical management of ED patients with severe PE with anticoagulation is poorly standardized and indicate a need for research to determine the appropriate threshold for empiric treatment when PE is suspected before diagnostic confirmation.

Despite its relatively common occurrence and life‐threatening potential, the management of angioedema in the emergency department (ED) is lacking in terms of a structured approach. It is paramount to distinguish the different etiologies of angioedema from one another and more specifically differentiate histaminergic‐mediated angioedema from bradykinin‐mediated angioedema, especially in lieu of the more novel treatments that have recently become available for bradykinin‐mediated angioedema. With this background in mind, this consensus parameter for the evaluation and management of angioedema attempts to provide a working framework for emergency physicians (EPs) in approaching the patient with angioedema in terms of diagnosis and management in the ED. This consensus parameter was developed from a collaborative effort among a group of EPs and leading allergists with expertise in angioedema. After rigorous debate, review of the literature, and expert opinion, the following consensus guideline document was created. The document has been endorsed by the American College of Allergy, Asthma & Immunology (ACAAI) and the Society for Academic Emergency Medicine (SAEM).

Background: Acute heart failure (AHF) is one of the most common diagnoses assigned to emergency department (ED) patients who are hospitalized. Despite its high prevalence in the emergency setting, the diagnosis of AHF in ED patients with undifferentiated dyspnea can be challenging.

Background The HEART Pathway is a decision aid designed to identify emergency department patients with acute chest pain for early discharge. No randomized trials have compared the HEART Pathway with usual care. Methods and Results Adult emergency department patients with symptoms related to acute coronary syndrome without ST-elevation on ECG (n=282) were randomized to the HEART Pathway or usual care. In the HEART Pathway arm, emergency department providers used the HEART score, a validated decision aid, and troponin measures at 0 and 3 hours to identify patients for early discharge. Usual care was based on American College of Cardiology/American Heart Association guidelines. The primary outcome, objective cardiac testing (stress testing or angiography), and secondary outcomes, index length of stay, early discharge, and major adverse cardiac events (death, myocardial infarction, or coronary revascularization), were assessed at 30 days by phone interview and record review. Participants had a mean age of 53 years, 16% had previous myocardial infarction, and 6% (95% confidence interval, 3.6%–9.5%) had major adverse cardiac events within 30 days of randomization. Compared with usual care, use of the HEART Pathway decreased objective cardiac testing at 30 days by 12.1% (68.8% versus 56.7%; P=0.048) and length of stay by 12 hours (9.9 versus 21.9 hours; P=0.013) and increased early discharges by 21.3% (39.7% versus 18.4%; P<0.001). No patients identified for early discharge had major adverse cardiac events within 30 days. Conclusions The HEART Pathway reduces objective cardiac testing during 30 days, shortens length of stay, and increases early discharges. These important efficiency gains occurred without any patients identified for early discharge suffering MACE at 30 days.