Modification of HEART Pathway for Patients With Chest Pain: A Korean Perspective
Bora Chae1, Shin Ahn2, Youn-Jung Kim1
1Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
Insights
The modified HEART pathway accurately identifies low-risk chest pain patients for early discharge. This revised pathway, using a higher obesity threshold, improved MACE identification in a Korean population.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Risk Stratification
Background:
- The HEART pathway aids in identifying low-risk patients with chest pain.
- Accurate risk stratification is crucial for timely emergency department discharge.
Purpose of the Study:
- To modify and evaluate the HEART pathway for chest pain patients in a Korean population.
- To assess the impact of adjusting the obesity BMI threshold on MACE risk identification.
Main Methods:
- Prospective enrollment of 1,304 chest pain patients.
- Modification of the HEART pathway using a 30 kg/m² obesity threshold instead of 25 kg/m².
- Primary outcome: Major Adverse Cardiac Event (MACE) within 30 days.
Main Results:
- The modified HEART pathway identified 37.3% of patients as low-risk.
- A lower incidence of MACE was observed in the low-risk group identified by the modified pathway (0.8% vs 1.6%).
- The modified pathway demonstrated high sensitivity (98.8%) and NPV (99.2%) for MACE detection.
Conclusions:
- The modified HEART pathway, utilizing Korean-specific BMI cut-offs, enhances the accurate identification of low-risk patients.
- This adaptation facilitates safer and more precise early discharge decisions for chest pain patients in Korea.
Background And Objectives:
The History, Electrocardiography, Age, Risk factors, and Troponin (HEART) pathway was developed to identify patients at low risk of a major adverse cardiac event (MACE) among patients presenting with chest pain to the emergency department.
Methods:
We modified the HEART pathway by replacing the Korean cut-off of 25 kg/m² with the conventional threshold of 30 kg/m² in the definition of obesity among risk factors. The primary outcome was a MACE within 30 days, which included acute myocardial infarction, primary coronary intervention, coronary artery bypass grafting, and all-cause death.
Results:
Of the 1,304 patients prospectively enrolled, MACE occurred in 320 (24.5%). The modified HEART pathway identified 37.3% of patients as low-risk compared with 38.3% using the HEART pathway. Of the 500 patients classified as low-risk with HEART pathway, 8 (1.6%) experienced MACE, and of the 486 low-risk patients with modified HEART pathway, 4 (0.8%) experienced MACE. The modified HEART pathway had a sensitivity of 98.8%, a negative predictive value (NPV) of 99.2%, a specificity of 49.0%, and a positive predictive value (PPV) of 38.6%, compared with the original HEART pathway, with a sensitivity of 97.5%, a NPV of 98.4%, a specificity of 50.0%, and a PPV of 38.8%.
Conclusions:
When applied to Korean population, modified HEART pathway could identify patients safe for early discharge more accurately by using body mass index cut-off levels suggested for Koreans.
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