The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early
Simon A Mahler1, Robert F Riley2, Brian C Hiestand2
1From the Department of Emergency Medicine (S.A.M., B.C.H., J.W.H., C.W.L., B.A.N., D.M.C., K.L.A., S.B.E., C.D.M.), Division of Cardiology, Department of Internal Medicine (R.F.R., D.M.H.), Department of Biostatistical Sciences (G.B.R.), and Division of Public Health Sciences (G.L.B.), Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC. smahler@wakehealth.edu.
Insights
The HEART Pathway (Heart Disease Risk Prediction Approach) safely reduces cardiac testing and hospital stays for emergency department patients with chest pain, increasing early discharges without compromising safety.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Decision Support
Background:
- The HEART Pathway is a validated decision aid for identifying emergency department patients with acute chest pain suitable for early discharge.
- No prior randomized trials have compared the HEART Pathway's effectiveness against usual care.
Purpose of the Study:
- To evaluate the efficacy of the HEART Pathway compared to usual care in managing adult emergency department patients presenting with symptoms suggestive of acute coronary syndrome without ST-elevation on ECG.
- To assess the impact of the HEART Pathway on objective cardiac testing, length of stay, early discharge rates, and major adverse cardiac events (MACE).
Main Methods:
- A randomized trial involving 282 adult patients with acute coronary syndrome symptoms (without ST-elevation).
- Patients were randomized to either the HEART Pathway (utilizing HEART score and serial troponin measurements) or usual care (based on ACC/AHA guidelines).
- Outcomes, including objective cardiac testing, length of stay, early discharge, and 30-day MACE, were assessed via phone interviews and record review.
Main Results:
- The HEART Pathway group showed a significant reduction in objective cardiac testing (12.1% decrease, P=0.048) and length of stay (12 hours shorter, P=0.013) compared to usual care.
- Early discharge rates were significantly higher in the HEART Pathway group (21.3% increase, P<0.001).
- No patients identified for early discharge experienced major adverse cardiac events within 30 days.
Conclusions:
- The HEART Pathway effectively reduces objective cardiac testing and length of hospital stay while increasing early discharges for selected emergency department patients.
- These efficiency improvements were achieved without an increase in 30-day major adverse cardiac events for patients discharged early.
Background:
The HEART Pathway is a decision aid designed to identify emergency department patients with acute chest pain for early discharge. No randomized trials have compared the HEART Pathway with usual care.
Methods And Results:
Adult emergency department patients with symptoms related to acute coronary syndrome without ST-elevation on ECG (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. 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% versus 56.7%; P=0.048) and length of stay by 12 hours (9.9 versus 21.9 hours; P=0.013) and increased early discharges by 21.3% (39.7% versus 18.4%; P<0.001). No patients identified for early discharge had major adverse cardiac events within 30 days.
Conclusions:
The HEART Pathway reduces objective cardiac testing during 30 days, shortens length of stay, and increases early discharges. These important efficiency gains occurred without any patients identified for early discharge suffering MACE at 30 days.
Clinical Trial Registration:
URL: http://www.clinicaltrials.gov. Unique Identifier: NCT01665521.
