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    HEART Pathway for Early Discharge in Acute Chest Pain

    Identifies emergency department patients with acute chest pain for early discharge.
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    INSTRUCTIONS

    Use in patients ≥21 years old presenting with symptoms suggestive of ACS. Do not use if new ST-segment elevation ≥1 mm or new other new EKG changes, hypotension, life expectancy less than 1 year, or noncardiac medical/surgical/psychiatric illness determined by the provider to require admission.

    When to Use
    Pearls/Pitfalls
    Why Use

    Patients ≥21 years old presenting in the emergency department with acute chest pain concerning for ACS.

    • The HEART Pathway was designed to aid in efficiently evaluating patients with acute chest pain using the previously validated HEART Score.
    • Identifies patients who are safe for early discharge versus those who need observation, admission, and potentially emergent cardiology assessment.
    • While patients with ischemic changes on EKG or elevated troponin may be classified as low risk using the HEART Pathway, the creators recommend not to rely on the HEART Pathway in cases like this. New elevations in troponin or EKG changes require further workup and should not be deemed low risk.
    • The creators of the HEART Pathway recommend against using this clinical decision tool in patients with known coronary artery disease as their disease state puts them at significant increased risk of ACS.
    • Designed for patients presenting to the emergency department with chest pain; not tested in already-hospitalized patients with chest pain.
    • Chest pain is one of the most common and potentially life-threatening chief complaints in emergency medicine. Many patients presenting with chest pain undergo unnecessarily extensive and costly evaluations to rule out ACS. The HEART Pathway can reduce the number of prolonged and invasive evaluations while maintaining high sensitivity and negative predictive value for ACS.
    • Unlike other scoring systems such as TIMI Risk Index or GRACE, the HEART Pathway is designed to predict the likelihood of ACS in the patient presenting to the emergency department with acute chest pain. TIMI and GRACE are used to risk stratify patients who have been diagnosed with ACS.
    About the Creator
    Dr. Simon A. Mahler
    Content Contributors
    • Cullen Clark, MD
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    Evidence
    Creator Insights

    Advice

    • The HEART Pathway is an accelerated diagnostic pathway (ADP). It is not designed to replace clinical judgment.
    • Any patient with a concerning presentation or clinical progression should receive workup and treatment based on the clinician’s discretion, regardless of the HEART Pathway’s predicted risk.
    • Shared decision making is a crucial part of further management after ACS risk has been determined, especially in patients with moderate risk who are recommended for observation and comprehensive cardiac evaluation. There is notable risk involved with hospitalization as well as risk of false-positive or non-diagnostic testing that would result in invasive procedures such as cardiac catheterization. The patient should be presented with the risk of both missed ACS and hospitalization for further workup. See the Chest Pain Choice Decision Aid from Mayo Clinic for risk-specific decision aids.
    • Any patient presenting with chest pain and subsequently discharged should be informed that even with a negative workup, there is still a small risk of ACS.  Patients should be set up with close follow-up and given extensive return precautions prior to discharge.

    Management

    • Low risk patients with a follow-up troponin (at 3 hours) can be considered for safe discharge home with appropriate follow-up.
    • High risk patients require admission, serial cardiac biomarkers and EKG, and cardiology consult.

    From Mahler 2015.

    Critical Actions

    • Clinician judgment should prevail, even if patients are deemed low risk by the HEART Pathway.  If there is some other cause for concern of acute cardiac event, workup should be individualized to the patient.
    • All patients presenting to the ED with chest pain concerning for ACS should receive aspirin unless there is an absolute contraindication (known allergy, active bleeding, or the patient has received a therapeutic dose prior to arrival).

    Formula

    Addition of the selected points:

     

    0 points

    1 point

    2 points

    History1

    Slightly suspicious

    Moderately suspicious

    Highly suspicious

    EKG

    Normal

    Non-specific repolarization disturbance2

    Significant ST depression3

    Age (years)

    <45

    45–65

    >65

    Risk factors4

    No known risk factors

    1–2 risk factors

    ≥3 risk factors or history of atherosclerotic disease

    Initial troponin5

    ≤normal limit

    1–2× normal limit

    >2× normal limit

    1. e.g. Retrosternal pain, pressure, radiation to jaw/left shoulder/arms, duration 5–15 min, initiated by exercise/cold/emotion, perspiration, nausea/vomiting, reaction on nitrates within mins, patient recognizes symptoms. Low risk features of chest pain include: well localized, sharp, non-exertional, no diaphoresis, no nausea or vomiting, and reproducible with palpation.
    2. LBBB, typical changes suggesting LVH, repolarization disorders suggesting digoxin, unchanged known repolarization disorders.
    3. Significant ST-segment depression or elevation without LBBB, LVH, or digoxin.
    4. HTN, hypercholesterolemia, DM, obesity (BMI >30 kg/m2), smoking (current, or smoking cessation ≤3 mo), positive family history (parent or sibling with CVD before age 65).
    5. Use local assays and corresponding cutoffs.

    Facts & Figures

    Interpretation:

    HEART Score

    Initial troponin

    Risk

    Recommendation

    ≤3

    0 points

    Low (0.9–1.7% 30-day MACE)

    Repeat troponin at 3 hours and if negative, discharge home with outpatient follow-up.

    1–2 points

    High (12–65% 30-day MACE)

    Cardiology consultation and admission recommended. Further testing indicated.

    ≥4

    0 points

    High (12–65% 30-day MACE)

    Admit to hospital or observation. Further testing indicated.

    1–2 points

    High (12–65% 30-day MACE)

    Cardiology consultation and admission recommended. Further testing indicated.

    Evidence Appraisal

    The HEART Pathway was developed by Mahler et al in 2015 in a randomized controlled single-center trial.

    • Control arm was managed at the discretion of care providers encouraged to follow American College of Cardiology/American Heart Association guidelines for acute chest pain.
    • The use of the HEART Pathway in this study was designed to mimic the real world in that it was used as an ADP.  Patient care was at the discretion of the health care provider and not mandated by the outcome of the HEART Pathway.
    • n = 282, with 141 patients in each treatment group.
    • Primary outcome: rate of objective cardiac testing (stress test, coronary CTA, or invasive coronary angiography) within 30 days of presentation.
    • Secondary outcomes: early discharge rate, index length of stay, cardiac related recurrent ED visits, and non-index hospitalization at 30 days.
    • The rate of objective cardiac testing in the HEART Pathway group was 12% less than the usual care group.
    • The rate of early discharge in the HEART Pathway was 21% higher than the usual care group.
    • The index length of stay was 12 hours shorter using the HEART Pathway.
    • There was no significant difference between the two groups for cardiac related recurrent ED visits or non-index hospitalization at 30 days.
    • No patients identified for early discharge in either group had missed MACE during the first 30 day follow up period.
    • Study was not powered to adequately detect difference in major adverse cardiac event (MACE) between the two study groups.

    Riley et al in 2017 published a cost analysis of the HEART Pathway compared to usual care using the same dataset as the original HEART Pathway trial.

    • n = 270, missing billing data of 12 patients from the original study.
    • Cost metrics considered in each group were index visit cost, total cost at 30 days, cardiac related health care cost at 30 days, cardiac and noncardiac diagnostic testing cost, ED cost, inpatient cost for index visit, and outpatient cost.
    • HEART Pathway patients had a significantly lower mean and median cost for both index visit and 30 day follow up.  
    • There was not a significant difference in cost between the median and mean costs of the other metrics.
    • Average savings per patient was $216 using the HEART Pathway.  On a larger scale, this would mean approximately $2 billion in savings per year for undifferentiated chest pain.

    Mahler and colleagues (2017) also published a secondary analysis looking at high sensitivity cardiac troponin (hs-cTnI and hs-cTnT).

    • Compared risk stratification using cardiac troponin I (cTnI) vs. high sensitivity cardiac troponin (hs-cTnI and hs-cTnT) in calculating the HEART Pathway score.
    • n = 133, patients had blood samples sent for cTnI, hs-cTnI, and hs-cTnT.
    • All of the troponin assays had poor sensitivity for predicting MACE when used separately from the HEART Score.
    • There was no difference in the predicted risk of MACE between the use of serial cTnI and 3-hour hs-cTnI in the HEART Pathway.
    • Using hs-cTnT in the HEART Pathway led one patient with an NSTEMI to be misclassified as low risk.
    • The study found the HEART Pathway using serial cTnI or 3-hour hs-cTnI to have sensitivity and NPV of 100% for 30-day MACE.
    • Although hs-cTnT use in the HEART Pathway caused an NSTEMI to be misclassified as low risk, the reduction in sensitivity was not statistically significant, given the small study population. The authors recommend further appropriately-powered studies to determine small differences in the accuracy of the high sensitivity troponin assays.
    Dr. Simon A. Mahler

    About the Creator

    Dr. Simon A. Mahler, MD, is an associate professor of emergency medicine at Wake Forest Baptist Health in Winston-Salem, North Carolina. He is board certified in emergency medicine and is also the chief medical officer of Decision Point Informatics, LLC. Dr. Mahler’s research interests include decision support in chest pain patients presenting to the emergency department.

    To view Dr. Simon A. Mahler's publications, visit PubMed

    Content Contributors
    • Cullen Clark, MD