Acute chest pain, the most common cause of ED visit, might be indicative of acute coronary syndrome (ACS), leading to over-cautiousness of ED physicians who subject >50% of these patients to a comprehensive cardiac evaluation. An ACS workup includes serial cardiac biomarkers, stress tests and/or angiography, and was shown to be unnecessary for >90% of patients with acute chest pain, and to result in $10-13 billion in healthcare spending.
Guidelines by the American Heart Association (AHA) advise thorough testing of all patients – including low-risk ones – presenting with acute chest pain, with ACS workup, starting with serial cardiac markers, and followed by stress testing and cardiac imaging if necessary.
Authors of a randomized control clinical trial, results of which were published in AHA’s Circulation: Cardiovascular Quality and Outcomes, argued that non-discriminatory testing of all patients with chest pain was detrimental to high-risk patients.1 ACS workup is often invasive and leads to a great majority of false-positive results.2 In addition, <2% of low-risk patients are diagnosed with ACS.
These observations prompted the need for improved triage of patients presenting to the ED with acute chest pain. A ‘HEART score’ was developed to evaluate risks of ACS in these patients; it takes History, ECG, Age, Risk factors, and Troponin into account.3 Scores of 0, 1, or 2 points are given for each one of these values.
In an endeavor to identify ED patients with acute chest pain who could be safely discharged, physicians at Wake Forest School of Medicine, Winston-Salem, NC, combined the HEART score and cardiac troponin tests at 0 and 3 hr, and dubbed it the ‘HEART Pathway’. Prior studies had shown that use of the HEART Pathway led to early and safe discharge of 20% of patients presenting with acute chest pain.4 Moreover, major adverse cardiac events (MACE) occurred in 0.6% vs 4.2% in low- vs high-risk patients, as assessed by HEART scores (P <.05).4 Furthermore, use of the HEART score had the potential to reduce cardiac testing by 84.5%, and a HEART score >3 showed 85% specificity (P <.05), and 58% sensitivity (P <.05). Adding serial troponin testing to the HEART score increased sensitivity to 100%, and had specificity of 83% (P <.05).
Results from a HEART Pathway randomized trial indicated that its use led to a 12.1% reduction in cardiac testing at 30 days (P =.048), shorter hospital stays (P =.013), and 21.3% increase in early discharges (P <.001).1 In addition, none of the patients discharged early experienced MACE in the 30 days following their ED visit.
Strong from results from this trial, study authors, Simon Mahler, MD and Iltifat Husain, MD, both assistant professors of emergency medicine at Wake Forest Baptist, sought to develop a smart phone application to facilitate use of the HEART Pathway protocol by ED physicians.
This HEART Pathway app, available free of charge, was released this spring, and integrates electronic health records (e.g. EPIC). In a statement, Dr Mahler said: “The HEART Pathway app is the manifestation of our validated patient protocol in digital form. This gives emergency department providers an easy way to apply an already proven method for evaluating patients who present with chest pain in a way that reduces length of stay and unnecessary testing.”
A HEAR score between 0 and 7 is determined by the app, and informs whether further troponin measurements are indicated. It was found that <1% of patients with a HEAR score ≤3 develop MACE within 30 days, making the HEAR score more accurate than the HEART score in predicting such events, as the latter is associated with a 2% risk of MACE. Moreover, the HEART pathway is highly reproducible, compared to the HEART score, and reduces subjective decisions by healthcare practitioners.
App developers are now looking to get the HEART Pathway tool adopted by emergency departments across the nations, to allow for improved patient care and a reduction in healthcare costs.
1. 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.
2. Hermann LK, Weingart SD, Duvall WL, Henzlova MJ. The limited utility of routine cardiac stress testing in emergency department chest pain patients younger than 40 years. Ann Emerg Med. 2009;54(1):12-6.
3. Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008;16(6):191-6.
4. Mahler SA, Hiestand BC, Goff DC, Hoekstra JW, Miller CD. Can the HEART score safely reduce stress testing and cardiac imaging in patients at low risk for major adverse cardiac events?. Crit Pathw Cardiol. 2011;10(3):128-33.