Safely Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge

Abstract

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

Comparison of usual care and the HEART score for effectively and safely discharging patients with low‐risk chest pain in the emergency department: would the score always help?

“…The methods for calculating the HEART score and HEART pathway have been previously described . The HEART score consisted of five elements: history, ECG, age, risk factors, and troponin.…”

“…It takes time to observe these changes, but currently used risk stratification scores merely focus on one cross‐section of the timeline during an ED stay . To solve this problem, a triage pathway, such as the HEART pathway, based on a clinical score and two serial cTn tests have been developed and evaluated . Only the change in cTn over time is considered.…”

Risk stratifying chest pain patients in the emergency department using HEART, GRACE and TIMI scores, with a single contemporary troponin result, to predict major adverse cardiac events

“…Others have adopted repeat cTn sampling at 2–3 hours in an ADP. This is not ideal for prompt ‘rule out’ but does appear to heighten diagnostic performance both for TIMI12 13 and HEART 29…”

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 .…”