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HEART Pathway effectively identifies patients with acute chest pain for early discharge
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Compared with usual care, use of the HEART Pathway for patients with acute chest pain reduced objective cardiac testing, hospitalization and length of stay, according to recent findings.
Moreover, none of the patients identified for early ED discharge using the HEART Pathway experienced an adverse cardiac event at 30 days, researchers wrote.
“Prospective observational and retrospective studies suggest that the HEART Pathway can safely identify low-risk patients with acute chest pain for early discharge from the emergency department without stress testing or coronary angiography,” the researchers wrote. “This is the first clinical trial to examine the real-time use of the HEART Pathway to guide chest pain risk stratification and disposition decisions.”
For the randomized, controlled, single-center clinical trial, researchers evaluated 282 adults with suspected ACS recruited from the ED of a tertiary medical center from September 2012 to February 2014. All participants were aged 21 years and older and had no ST-elevation on EEG. The mean patient age was 53 years, and 16% had a previous MI.
The researchers randomly assigned the participants to the HEART Pathway (n=141) or usual care (n=141). ED providers risk-stratified the participants in the HEART Pathway arm using a validated clinical decision aid, the HEART score, and serial troponin measures at 0 and 3 hours after ED presentation. On the basis of these measures, care recommendations were made to attending physicians according to the HEART Pathway. Patients with low-risk HEART scores (0-3) and negative troponin results were identified for ED discharge without further testing.
The usual-care arm group administered care at the discretion of providers, with practitioners advised to follow American College of Cardiology/American Heart Association guidelines.
The primary outcome was the prevalence of objective cardiac testing (stress testing modality, coronary computed tomographic angiography, or invasive coronary angiography) within 30 days of ED presentation. Early discharge was defined as ED discharge without objective cardiac testing.
Six percent of patients had major adverse cardiac events within 30 days of randomization. Patients randomly assigned to the HEART Pathway had a 30-day objective cardiac testing rate of 56.7% vs. 68.8% in the usual-care group (P = .048), which equaled an absolute decrease of 12.1% (P = .048). Patients randomly assigned to the HEART Pathway had a median length of stay of 9.9 hours vs. 21.9 hours in the usual-care group, equaling a median decrease of 12 hours (P = .013). None of the patients identified for early discharge experienced major adverse cardiac events within 30 days. Similarly, the HEART Pathway was not associated with increased cardiac-related return ED visits or non-index hospitalizations.
“The results of this small, single-center trial require additional validation,” the researchers wrote. “However, when our results are considered in the context of previous HEART Pathway and HEART score analyses, there is strong evidence to support a multicenter trial of structured HEART Pathway implementation.” – by Jennifer Byrne
Disclosure: The researchers report no relevant financial disclosures.
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