HEART Pathway Acute Chest Pain for Early Discharge

Helps clinicians determine whether early discharge from emergency department is possible and safe.

Refer to the text below the calculator for more information on the model and its usage.


The HEART Pathway is an accelerated diagnostic pathway designed to be used in the emergency room on patients of 21 years or older, presenting with acute chest pain.

It is a model that has shown a high sensitivity and negative predictive value for ACS and may be used for identifying patients that are eligible for a safe early discharge, as opposed to those in need for emergent cardiology assessment.


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

HEART Score Initial troponin 30-day risk of MACE Recommendation
≤3 ≤ normal limit (0) Low (0.9-1.7%) Repeat troponin at 3 hours and if negative – safe to discharge home with outpatient follow-up scheduled
1-3x normal limit (+1)
>3x normal limit (+2)
High (12-65%) Cardiology consultation and admission recommended
≥4 ≤ normal limit (0) Admission to hospital or observation for further testing
1-3x normal limit (+1)
>3x normal limit (+2)
Cardiology consultation, admission recommended and further testing

1

History

2

EKG

1 point: No ST depression but LBBB, LVH, repolarization changes (ex: digoxin); 2 points: ST depression/elevation not due to LBBB, LVH, or digoxin
3

Age

4

Risk factors

Risk factors: 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); atherosclerotic disease: prior MI, PCI/CABG, CVA/TIA, or peripheral arterial disease
5

Initial troponin

Use local assays and corresponding cutoffs
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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:

HEART Pathway Variables Answer Choices Pts
Patient history Slightly suspicious 0
Moderately suspicious 1
Highly suspicious 2
EKG findings
1 point: No ST depression but LBBB, LVH, repolarization changes (ex: digoxin); 2 points: ST depression/elevation not due to LBBB, LVH, or digoxin
Normal 0
Non-specific repolarization disturbance 1
Significant ST depression 2
Age <45 0
45-64 1
≥65 2
Risk factors
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); atherosclerotic disease: prior MI, PCI/CABG, CVA/TIA, or peripheral arterial disease
No known risk factors 0
1-2 risk factors 1
≥3 risk factors or history of atherosclerotic disease 2
Initial troponin
Use local assays and corresponding cutoffs
≤ normal limit 0
1-3x normal limit 1
>3x normal limit 2

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:

HEART Score Initial troponin 30-day risk of MACE Recommendation
≤3 ≤ normal limit (0) Low (0.9-1.7%) Repeat troponin at 3 hours and if negative – safe to discharge home with outpatient follow-up scheduled
1-3x normal limit (+1)
>3x normal limit (+2)
High (12-65%) Cardiology consultation and admission recommended
≥4 ≤ normal limit (0) Admission to hospital or observation for further testing
1-3x normal limit (+1)
>3x normal limit (+2)
Cardiology consultation, admission recommended and further testing

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.


Specialty: Cardiology

System: Cardiovascular

Year Of Study: 2015

Article By: Denise Nedea

Published On: October 20, 2020

Last Checked: October 20, 2020

Next Review: October 20, 2025