HEART Pathway Implementation Safely Reduces Hospitalizations at One Year in Patients With Acute Chest Pain
Jason P Stopyra1, Anna C Snavely2, Kristin M Lenoir2
1Departments of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
Insights
The HEART Pathway safely identifies low-risk acute coronary syndrome patients in the ED, reducing hospitalizations without increasing adverse events. This clinical decision tool improves care for emergency department patients.
Area of Science:
- Cardiology
- Emergency Medicine
- Health Informatics
Background:
- Acute coronary syndrome (ACS) poses a significant diagnostic challenge in emergency departments (EDs).
- Effective risk stratification is crucial for timely and appropriate patient management.
- The HEART Pathway (History, ECG, Age, Risk Factors, Troponin) offers a structured approach to assess ACS risk.
Purpose of the Study:
- To evaluate the safety and effectiveness of implementing the HEART Pathway in ED patients with possible ACS.
- To assess the impact of the HEART Pathway on patient outcomes at 1-year follow-up.
Main Methods:
- A prospective pre-post study involving 8,474 adult ED patients with possible ACS across 3 US sites.
- The HEART Pathway was integrated as an electronic health record decision support tool.
- Safety (death, myocardial infarction) and effectiveness (hospitalization) were tracked for 1 year post-implementation.
Main Results:
- The HEART Pathway identified 30.7% of patients as low risk, with 97.5% experiencing no death or myocardial infarction within 1 year.
- Hospitalizations were reduced by 7.0% in the postimplementation cohort compared to preimplementation (62.1% vs. 69.1%).
- Rates of death or myocardial infarction remained similar between cohorts (11.6% vs. 12.4%).
Conclusions:
- HEART Pathway implementation is safe and effective for managing ED patients with possible ACS.
- The pathway is associated with decreased hospitalizations and low adverse event rates in low-risk patients.
- This clinical decision support tool can optimize care for patients presenting with potential acute coronary syndrome.
Study Objective:
We determine whether implementation of the HEART (History, ECG, Age, Risk Factors, Troponin) Pathway is safe and effective in emergency department (ED) patients with possible acute coronary syndrome through 1 year of follow-up.
Methods:
A preplanned analysis of 1-year follow-up data from a prospective pre-post study of 8,474 adult ED patients with possible acute coronary syndrome from 3 US sites was conducted. Patients included were aged 21 years or older, evaluated for possible acute coronary syndrome, and without ST-segment elevation myocardial infarction. Accrual occurred for 12 months before and after HEART Pathway implementation, from November 2013 to January 2016. The HEART Pathway was integrated into the electronic health record at each site as an interactive clinical decision support tool. After integration, ED providers prospectively used the HEART Pathway to identify patients with possible acute coronary syndrome as low risk (appropriate for early discharge without stress testing or angiography) or nonlow risk (appropriate for further inhospital evaluation). Safety (all-cause death and myocardial infarction) and effectiveness (hospitalization) at 1 year were determined from health records, insurance claims, and death index data.
Results:
Preimplementation and postimplementation cohorts included 3,713 and 4,761 patients, respectively. The HEART Pathway identified 30.7% of patients as low risk; 97.5% of them were free of death and myocardial infarction within 1 year. Hospitalization at 1 year was reduced by 7.0% in the postimplementation versus preimplementation cohort (62.1% versus 69.1%; adjusted odds ratio 0.70; 95% confidence interval 0.63 to 0.78). Rates of death or myocardial infarction at 1 year were similar (11.6% versus 12.4%; adjusted odds ratio 1.00; 95% confidence interval 0.87 to 1.16).
Conclusion:
HEART Pathway implementation was associated with decreased hospitalizations and low adverse event rates among low-risk patients at 1-year follow-up.
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