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Accelerated diagnostic protocol determines risk in patients with chest pain
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An accelerated diagnostic protocol to identify patients who present to the ED with chest pain as low risk and for early discharge without further testing increased the identification of MI and decreased hospitalizations, according to a study published in Circulation: Cardiovascular Quality and Outcomes.
The protocol also conferred very low rates of death and MI among patients who were considered low risk, according to the study.
“These findings demonstrate that the HEART Pathway is a safe and effective way to determine which patients with acute chest pain are low risk for acute cardiac syndrome,” Simon A. Mahler, MD, associate professor of emergency medicine at Wake Forest Baptist Medical Center in Winston-Salem, North Carolina, said in a press release. “Given its ability to reduce the utilization of health care resources, the protocol may provide a model for health systems to provide safe and high-value care to emergency room patients with chest pain at lower cost.”
HEART Pathway implementation
Researchers analyzed data from 8,474 patients (median age, 54 years; 54% women) who reported to the ED with acute chest pain and were investigated for possible ACS before (n = 3,713) and after (n = 4,761) the HEART Pathway accelerated diagnostic protocol was implemented at three hospitals between November 2013 and January 2016. Patients did not have evidence of STEMI on ECG, and at least one troponin measurement was ordered during the ED visit.
The HEART Pathway accelerated diagnostic protocol was integrated into each of the hospitals’ electronic health records system as an interactive clinical decision support tool. Once implemented, providers saw a pop-up alert that prompted them to answer questions to risk-stratify a patient.
Patients were classified as non-low risk for ACS if they had known CAD or acute ischemic changes on ECG. Further steps such as ECG, history, age and risk score calculation were not completed in these patients.
Those who did not have known CAD, STEMI or acute ischemic ECG changes were asked additional questions to determine patient history, age, ECG and a risk factor score, which was based on the HEART Pathway trial algorithm that used troponin measures. Patients were categorized as low risk if they had a score of 3 or lower without elevated troponin measures and did not have to undergo objective cardiac testing.
Those who had a risk score of at least 4, known CAD, elevated troponin or ischemic ECG changes were considered non-low risk and underwent further testing and/or admission.
Additional data were obtained from EHR data to collect information on patient demographics, CV risk factors, medical history, troponin results, comorbidities, HEART Pathway assessment, diagnoses, disposition and vital status.
The primary effectiveness outcome was 30-day hospitalization rate. Primary safety outcomes were defined as acute MI or death during the index visit and within 30-day follow-up. One of the secondary endpoints was major adverse CV events, which was a composite of MI, death and revascularization.
The accelerated diagnostic protocol identified 30.7% of patients as low risk and 53.2% as non-low risk. Of the low-risk patients, 0.4% had an MI or died within 30 days.
Major adverse CV events
MIs were detected in 6.6% of patients in the post-implementation group during the index visit compared with 5.7% of those in the pre-implementation group (adjusted OR = 1.36; 95% CI, 1.12-1.65).
Compared with patients assessed before the accelerated diagnostic protocol was implemented, the number of patients that were hospitalized after the protocol was implemented decreased by 6 percentage points (55.6% vs. 61.6%; 95% CI, 3.9-8.1; aOR = 0.79; 95% CI, 0.71-0.87).
During 30 days of follow-up, rates of MI and death were similar for patients in the post-implementation and pre-implementation groups (1.1% vs. 1.3%, respectively; aOR = 0.88; 95% CI, 0.58-1.33).
“This study may provide a model for U.S. health systems to provide safe and high-value care to the 8 [million to] 10 million patients who present to a U.S. ED with acute chest pain each year,” Mahler and colleagues wrote. “Our data add to a growing body of evidence suggesting that current practice guidelines should be changed, so that stress tests or cardiac imaging are no longer recommended for most low-risk patients presenting to the ED with chest pain.” – by Darlene Dobkowski
Disclosures: Mahler reports he received research funding from Abbott Point of Care, Roche Diagnostics and Siemens, consultant honoraria from Roche Diagnostics and is the chief medical officer for Impathiq Inc. Please see the study for all other authors’ relevant financial disclosures.
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