Adherence to an Accelerated Diagnostic Protocol for Chest Pain: Secondary Analysis of the HEART Pathway Randomized Trial

Abstract

Objectives Accelerated diagnostic protocols (ADP), such as the HEART Pathway, are gaining popularity in emergency departments (EDs) as tools used to risk-stratify patients with acute chest pain. However, provider non-adherence may threaten the safety and effectiveness of ADPs. The objective of this study was to determine the frequency and impact of ADP non-adherence. Methods A secondary analysis of participants enrolled in the HEART Pathway RCT was conducted. This trial enrolled 282 adult ED patients with symptoms concerning for acute coronary syndrome without ST-elevation on electrocardiogram. Patients randomized to the HEART Pathway (N = 141) were included in this analysis. Outcomes included index visit disposition, non-adherence, and major adverse cardiac events (MACE) at 30 days. MACE was defined as death, myocardial infarction, or revascularization. Non-adherence was defined as: 1) under-testing: discharging a high-risk patient from the ED without objective testing (stress testing or coronary angiography); or 2) over-testing: admitting or obtaining objective testing on a low-risk patient. Results Non-adherence to the HEART Pathway occurred in 28 out of 141 patients (20%, 95% CI = 14% to 27%). Over-testing occurred in 19 of 141 patients (13.5%, 95% CI = 8% to 19%) and under-testing in 9 of 141 patients (6%, 95% CI = 3% to 12%). None of these 28 patients suffered MACE. The net effect of non-adherence was ten additional admissions among patients identified as low-risk and appropriate for early discharge (absolute decrease in discharge rate of 7%, 95% CI = 3% to 13%). Conclusions Real-time use of the HEART Pathway resulted in a non-adherence rate of 20%, mostly due to over-testing. None of these patients had MACE within 30 days. Non-adherence decreased the discharge rate, attenuating the HEART Pathway’s impact on health care use.

Prehospital Modified HEART Score Predictive of 30-Day Adverse Cardiac Events

“…A recent randomized trial showed that, compared to usual care, use of the HEART Pathway increased early discharges by 21.3%, decreased length of stay in the hospital by 12 hours, and decreased objective cardiac testing at 30 days by 12.0% without increasing adverse events. 15,16 The use of the HEART Pathway as a decision aid for patients with undifferentiated chest pain has also shown a significant cost savings. 17 The prehospital arena is a natural extension of this work due to the large number of patients that present to the ED via ambulance.…”

Improved Assessment of Chest pain Trial (IMPACT): assessing patients with possible acute coronary syndromes

“…While the ADAPT accelerated diagnostic protocol (ADP) identified 20% of patients as low risk in clinical practice, most (79%) underwent further outpatient investigations for coronary artery disease 23 . A small randomised trial of the HEART pathway (282 participants) found a 21% increase in early discharges, and objective testing of low risk patients was reduced by 12%; 24 non‐adherence by providers to the HEART pathway affected 20% of patients 25 . A randomised study of the EDACS and ADAPT ADPs found that 41.6% and 30.5% of patients (respectively) were at low risk, but continued to recommend early investigation in an ambulatory setting because of the observational nature of the original trials 18 .…”

“…23 A small randomised trial of the HEART pathway (282 participants) found a 21% increase in early discharges, and objective testing of low risk patients was reduced by 12%; 24 nonadherence by providers to the HEART pathway affected 20% of patients. 25 A randomised study of the EDACS and ADAPT ADPs found that 41.6% and 30.5% of patients (respectively) were at low risk, but continued to recommend early investigation in an ambulatory setting because of the observational nature of the original trials. 18 Similar to IMPACT, these ADPs apply early troponin testing (0 and 2 hours for EDACS and ADAPT; 0 and 3 hours for HEART) and a risk stratification score (EDACS, Thrombolysis In Myocardial Infarction [TIMI], or HEART) to identify low risk patients.…”

Implementation of a Risk Stratification and Management Pathway for Acute Chest Pain in the Emergency Department

“…Our nonadherence rate was even higher than those reported in other recent investigations, which also show providers tend to be more conservative with diagnostic ordering without clinical benefit in the low-risk cohort as defined by the HEART score. 15 …”