Identifying ED Patients With Acute Chest Pain for Early Discharge

Study Questions:

Is the implementation of the HEART Pathway, an electronic health record (EHR)-based clinical decision support tool, associated with improved safety and decreased utilization in patients presenting to the emergency department (ED) with acute chest pain?


The HEART Pathway is triggered by patients presenting with chest pain with at least one troponin ordered. The tool prompts providers with a series of questions to risk-stratify eligible patients in real time, classifying patients as either low-risk for acute coronary syndrome or non–low-risk based on the HEART score incorporating troponin levels. Enrollment was comprised of 3,713 patients presenting with acute chest pain, but no ST-segment elevation myocardial infarction (MI) on electrocardiography at three hospitals in North Carolina over 12 months pre-implementation of HEART, and 4,761 patients over 12 months post-implementation. The primary effectiveness outcome of hospitalization rate at 30 days and the primary safety outcome was death/MI at 30 days.


Overall the cohort consisted of 54% women and 29% African Americans, with a median age of 54 years, and an overall death/MI rate of 6.5%. Differences between patients in the pre- and post-implementation phases were minor. The HEART Pathway identified 31% as low-risk and 53% as non–low-risk. Among those classified as low-risk, six patients (0.4%) met the outcome of death/MI. More MIs were detected in the post-implementation period (6.6% vs. 5.7%), but there were no differences in the primary safety outcome (1.3% vs. 1.1%) or death (0.2% vs. 0.3%) between the pre- and post-implementation periods. Overall, healthcare utilization was notably decreased with HEART: There was a 6% decrease in hospitalizations, more frequent early discharge (43% vs. 37%), less frequent stress testing or angiography (31% vs. 35%), and shorter length of stay (16 hours vs. 18 hours). Last, nonadherence to the HEART pathway guidance occurred in 16% of low-risk and 1.2% of non–low-risk patients.


In this multicenter implementation of an EHR-based clinical decision support tool, healthcare utilization significantly decreased, all the while minimizing adverse events at 30 days.


This study is a good example of how EHR-based interventions can lead to improved safety outcomes while reducing utilization and costs. While small in magnitude, large-scale implementation could lead to substantial savings in healthcare resources. Yet we are only scratching the surface. The HEART Pathway uses a basic scoring system, interrupts workflow requiring physician input, and likely contributes to EHR alert fatigue. With the creation of large, well-characterized registries (i.e., big data), the use of machine learning in healthcare, and the adoption of human-centered design, it is conceivable that better algorithms and processes requiring minimal human input will lead to even better risk stratification, personalized care, and an overall more cost-effective healthcare system.

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

Keywords: Acute Coronary Syndrome, Angiography, Chest Pain, Decision Support Systems, Clinical, Electrocardiography, Electronic Health Records, Emergency Service, Hospital, Exercise Test, Myocardial Infarction, Patient Discharge, Risk Assessment, Secondary Prevention, Troponin

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