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