HEART Pathway Acute Chest Pain for Early Discharge

The HEART Pathway for Early Discharge Explained

HEART Pathway was developed to help with the management of patients who present to the emergency department with acute chest pain, with respect to identifying patients that are eligible for a safe early discharge, as opposed to those in need for emergent cardiology assessment.

The model may be used in patients of 21 years or older with acute chest pain concerning for ACS but not if any of the following is present:

• new ST-segment elevation ≥1 mm or other new EKG changes;
• known coronary artery disease;
• hypotension;
• life expectancy less than 1 year;
• noncardiac medical/surgical/psychiatric illness.

The model developed by Mahler et al. in 2015 following a randomized controlled single-center trial relies on the following variables:

In the original study, there were two types of outcomes:

• Primary outcome, including rate of objective cardiac testing (stress test, coronary CTA, or invasive coronary angiography) within 30 days of presentation.
• Secondary outcomes, including early discharge rate, index length of stay, cardiac related recurrent ED visits, and non-index hospitalization at 30 days.

It was found that when the HEART Pathway was employed, the rate of objective cardiac testing was 12% less and the rate of early discharge was 21% higher, whilst the index length of hospital stay was 12 hours shorter.

Please note than whilst the model may, in some cases, classify patients with ischemic changes on EKG or elevated troponin as low risk, the model itself should not be solely relied upon and new elevations in troponin or EKG changes require further assessment.

Usually, high risk patients will require admission, serial cardiac biomarkers and EKG, and cardiology consult.

The HEART Pathway score interpretation is summarized in conjunction with troponin values below:

The HEART Pathway may be used as a clinical decision tool to rule out ACS in cases where extensive and costly cardiac evaluations may not be necessary. The model has shown a high sensitivity and negative predictive value for ACS and was found to reduce the number of prolonged and invasive evaluations.

Clinicians using the HEART Pathway should also note the important of informing patients that are eligible for safe discharge of the small risk of ACS undiagnosed and patients should be scheduled for appropriate follow up.

References

Original reference

Mahler SA, Riley RF, Hiestand BC, et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes. 2015; 8(2):195-203.

Other references

Riley RF, Miller CD, Russell GB, et al. Cost analysis of the History, ECG, Age, Risk factors, and initial Troponin (HEART) Pathway randomized control trial. Am J Emerg Med. 2017;35(1):77-81.

Poldervaart JM, Reitsma JB, Backus BE, et al. Effect of Using the HEART Score in Patients With Chest Pain in the Emergency Department: A Stepped-Wedge, Cluster Randomized Trial. Ann Intern Med. 2017.

Mahler SA, Stopyra JP, Apple FS, et al. Use of the HEART Pathway with high sensitivity cardiac troponins: A secondary analysis. Clin Biochem. 2017.