Safety and Effectiveness of the High-Sensitivity Cardiac Troponin HEART Pathway in Patients With Possible Acute
Simon A Mahler1,2,3, Nicklaus P Ashburn1,4, Brennan E Paradee1
1Department of Emergency Medicine (S.A.M., N.P.A., B.E.P., J.P.S., J.C.O., A.C.S.), Wake Forest University School of Medicine, Winston-Salem, NC.
Insights
The high-sensitivity HEART Pathway (hs-HP) safely increased early discharges for patients with possible acute coronary syndrome. This approach improved chest pain care by reducing hospitalizations without raising adverse events like death or myocardial infarction.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Risk Stratification
Background:
- The HEART Pathway (History, Electrocardiogram, Age, Risk factors, Troponin) aids in risk stratification for acute coronary syndrome (ACS).
- Data on the safety and effectiveness of the high-sensitivity HEART Pathway (hs-HP) in emergency departments is limited.
Purpose of the Study:
- To evaluate the safety and effectiveness of a modified high-sensitivity HEART Pathway (hs-HP) for risk stratification in emergency department patients with possible ACS.
- To assess the impact of hs-HP implementation on key safety and effectiveness outcomes, including early discharge rates.
Main Methods:
- An interrupted time series study involving 26,126 adult patients across 5 North Carolina sites.
- Comparison of preimplementation (traditional HEART Pathway with contemporary troponin) and postimplementation (modified hs-HP with high-sensitivity troponin) cohorts.
- Primary outcomes included 30-day all-cause death or myocardial infarction (MI) and 30-day hospitalizations; secondary outcome was early discharge rate.
Main Results:
- No significant difference in 30-day death or MI rates between hs-HP (6.8%) and traditional HEART Pathway (7.7%) implementation (aOR, 1.00).
- hs-HP implementation was associated with a significant increase in early discharges (63.6% vs. 43.7%; aOR, 2.22) and a decrease in 30-day hospitalizations (31.4% vs. 47.5%; aOR, 0.51).
- Among early discharge patients, 30-day death or MI rates were low and similar between cohorts (0.5% postimplementation vs. 0.4% preimplementation).
Conclusions:
- Implementation of a modified hs-HP is safe and effective for risk stratification in emergency department patients with possible ACS.
- The hs-HP strategy is associated with increased early discharges and reduced hospitalizations without compromising patient safety.
- Findings support the adoption of the modified hs-HP to enhance the efficiency and effectiveness of chest pain care in the emergency department.
Background:
The HEART Pathway (History, Electrocardiogram, Age, Risk factors, Troponin) can be used with high-sensitivity cardiac troponin to risk stratify emergency department patients with possible acute coronary syndrome. However, data on whether a high-sensitivity HEART Pathway (hs-HP) are safe and effective is lacking.
Methods:
An interrupted time series study was conducted at 5 North Carolina sites in 26 126 adult emergency department patients being investigated for possible acute coronary syndrome and without ST-segment-elevation myocardial infarction. Patients were accrued into 16-month preimplementation and postimplementation cohorts with a 6-month wash-in phase. Preimplementation (January 2019 to April 2020), the traditional HEART Pathway was used with 0- and 3-hour contemporary troponin measures (Siemens). In the postimplementation period (November 2020 to February 2022), a modified hs-HP was used with 0- and 2-hour high-sensitivity cardiac troponin (Beckman Coulter) measures. The primary safety and effectiveness outcomes were 30-day all-cause death or myocardial infarction and 30-day hospitalizations. These outcomes and early discharge rate (emergency department discharge without stress testing or coronary angiography) were determined from health records and death index data. Outcomes were compared preimplementation versus postimplementation using χ2 tests and multivariable logistic regression to adjust for potential confounders.
Results:
Preimplementation and postimplementation cohorts included 12 317 and 13 809 patients, respectively, of them 52.7% (13 767/26 126) were female with a median age of 54 years (interquartile range, 42-66). Rates of 30-day death or MI were 6.8% (945/13 809) postimplementation and 7.7% (948/12 317) preimplementation (adjusted odds ratio, 1.00 [95% CI, 0.90-1.11]). hs-HP implementation was associated with 19.9% (95% CI, 18.7%-21.1%) higher early discharges (post versus pre: 63.6% versus 43.7%; adjusted odds ratio, 2.22 [95% CI, 2.10-2.35]). The hs-HP was also associated with 16.1% (95% CI, 14.9%-17.3%) lower 30-day hospitalizations (postimplementation versus preimplementation, 31.4% versus 47.5%; adjusted odds ratio, 0.51 [95% CI, 0.48-0.54]). Among early discharge patients, death or myocardial infarction occurred in 0.5% (41/8780) postimplementation versus 0.4% (22/5383) preimplementation (P=0.61).
Conclusions:
hs-HP implementation is associated with increased early discharges without increasing adverse events. These findings support the use of a modified hs-HP to improve chest pain care.
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