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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 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.
    Slightly suspicious
    0
    Moderately suspicious
    +1
    Highly suspicious
    +2
    Normal
    0
    Non-specific repolarization disturbance
    +1
    Significant ST depression
    +2
    <45
    0
    45-64
    +1
    ≥65
    +2
    No known risk factors
    0
    1-2 risk factors
    +1
    ≥3 risk factors or history of atherosclerotic disease
    +2
    ≤normal limit
    0
    1–2× normal limit
    +1
    >2× normal limit
    +2

    Result:

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    Next Steps
    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).
    Content Contributors
    About the Creator
    Dr. Simon A. Mahler
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