Acute Chest Pain in the ED and Early Discharge | Journal Scan

Study Questions:

What is the real-time use of the HEART Pathway to guide chest pain risk stratification and disposition decisions?


The HEART Pathway, which combines the HEART score, with 0- and 3-hour cardiac troponin tests, is a recently developed decision aid designed to identify emergency department patients who are safe for early discharge. Adult emergency department patients with symptoms related to acute coronary syndrome without ST-elevation on electrocardiogram (n = 282) were randomized to the HEART Pathway or usual care. In the HEART Pathway arm, emergency department providers used the HEART score, a validated decision aid, and troponin measures at 0 and 3 hours to identify patients for early discharge. Usual care was based on American College of Cardiology/American Heart Association guidelines. The primary outcome, objective cardiac testing (stress testing or angiography), and secondary outcomes, index length of stay, early discharge, and major adverse cardiac events (death, myocardial infarction, or coronary revascularization), were assessed at 30 days by phone interview and record review.


Between September 2012 and February 2014, 282 patients with symptoms suggestive of acute coronary syndrome were enrolled, with 141 randomized to each study arm. Participants had a mean age of 53 years, 16% had previous myocardial infarction, and 6% (95% confidence interval, 3.6%–9.5%) had major adverse cardiac events within 30 days of randomization. Compared with usual care, use of the HEART Pathway decreased objective cardiac testing at 30 days by 12.1% (68.8% vs. 56.7%; p = 0.048) and length of stay by 12 hours (9.9 vs. 21.9 hours; p = 0.013) and increased early discharges by 21.3% (39.7% vs. 18.4%; p < 0.001). No patients identified for early discharge had major adverse cardiac events within 30 days.


The authors concluded that HEART Pathway reduces objective cardiac testing during 30 days, shortens length of stay, and increases early discharges.


This open-label study suggests that the HEART Pathway substantively reduces health care utilization (objective cardiac testing, hospitalization, and hospital length of stay) among patients with symptoms related to acute coronary syndrome. Moreover, the HEART Pathway strategy was not associated with increased cardiac-related return emergency department visits or nonindex hospitalizations. The results of this small single-center open-label trial require additional validation in a multicenter trial of HEART Pathway implementation. In addition, the impact of the use of high-sensitivity troponin assays (to be available in the near future) on the sensitivity and specificity of the HEART pathway needs to be studied.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Chest Pain, Emergency Service, Hospital, Electrocardiography, Decision Support Techniques, Length of Stay, Myocardial Infarction, Angiography, Exercise Test, Troponin

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