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Comparison of accelerated diagnostic pathways for acute chest pain risk stratification
Jason Stopyra1, Anna Catherine Snavely2, Brian Hiestand3
1Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA jstopyra@wakehealth.edu.
Insights
The HEART Pathway identified fewer low-risk patients but had a lower missed major adverse cardiac events rate than EDACS. Physicians should consider risk tolerance when choosing between these chest pain diagnostic pathways.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Risk Stratification
Background:
- The History Electrocardiogram Age Risk factor Troponin (HEART) Pathway and Emergency Department Assessment of Chest pain Score (EDACS) are established accelerated diagnostic pathways for chest pain evaluation.
- Limited data exists from large prospective studies comparing these pathways in real-world emergency department settings.
Purpose of the Study:
- To compare the performance of the HEART Pathway and EDACS in risk stratification of patients with symptoms concerning for acute coronary syndrome.
- To evaluate the detection rates of major adverse cardiac events (MACE) by both pathways.
Main Methods:
- A prospective, three-site cohort study involving adults presenting with chest pain.
- Physicians utilized electronic health records to apply both HEART Pathway and EDACS risk assessments.
- Major adverse cardiac events (death, myocardial infarction, coronary revascularization) were tracked for 30 days post-presentation.
Main Results:
- Of 4399 patients assessed, the HEART Pathway identified 38.4% as low-risk versus 58.1% by EDACS (p<0.001).
- The HEART Pathway demonstrated a significantly lower MACE rate in low-risk patients (0.4%) compared to EDACS (1.0%, p<0.001).
- The HEART Pathway achieved a higher negative predictive value (99.6%) for MACE than EDACS (99.0%).
Conclusions:
- EDACS classifies more patients as low-risk, but the HEART Pathway exhibits a superior safety profile with fewer missed major adverse cardiac events.
- Clinical decision-making regarding pathway adoption should incorporate physician and institutional risk tolerance.
Background:
The History Electrocardiogram Age Risk factor Troponin (HEART) Pathway and Emergency Department Assessment of Chest pain Score (EDACS) are validated accelerated diagnostic pathways designed to risk stratify patients presenting to the emergency department with chest pain. Data from large multisite prospective studies comparing these accelerated diagnostic pathways are limited.
Methods:
The HEART Pathway Implementation is a prospective three-site cohort study, which accrued adults with symptoms concerning for acute coronary syndrome. Physicians completed electronic health record HEART Pathway and EDACS risk assessments on participants. Major adverse cardiac events (death, myocardial infarction and coronary revascularisation) at 30 days were determined using electronic health record, insurance claims and death index data. Test characteristics for detection of major adverse cardiac events were calculated for both accelerated diagnostic pathways and McNemar's tests were used for comparisons.
Results:
5799 patients presenting to the emergency department were accrued, of which HEART Pathway and EDACS assessments were completed on 4399. Major adverse cardiac events at 30 days occurred in 449/4399 (10.2%). The HEART Pathway identified 38.4% (95% CI 37.0% to 39.9%) of patients as low-risk compared with 58.1% (95% CI 56.6% to 59.6%) identified as low-risk by EDACS (p<0.001). Major adverse cardiac events occurred in 0.4% (95% CI 0.2% to 0.9%) of patients classified as low-risk by the HEART Pathway compared with 1.0% (95% CI 0.7% to 1.5%) of patients identified as low-risk by EDACS (p<0.001). Thus, the HEART Pathway had a negative predictive value of 99.6% (95% CI 99.1% to 99.8%) for major adverse cardiac events compared with a negative predictive value of 99.0% (95% CI 98.5% to 99.3%) for EDACS.
Conclusions:
EDACS identifies a larger proportion of patients as low-risk than the HEART Pathway, but has a higher missed major adverse cardiac events rate at 30 days. Physicians will need to consider their risk tolerance when deciding whether to adopt the HEART Pathway or EDACS accelerated diagnostic pathway.
Trial Registration Number:
NCT02056964.
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