Accelerated diagnostic protocol safely identifies low-risk patients with chest pain
Safely Identifying Emergency Department Patients with Acute Chest Pain for Early Discharge: The HEART Pathway Accelerated Diagnostic ProtocolLiterature - Mahler SA, Lenoir KM, Wells BJ, et al. - Circulation 2018; published online ahead of print
Introduction and methods
Less than 10% of patients admitted to the emergency department (ED) with chest pain do indeed suffer an acute coronary syndrome (ACS), however, an extensive diagnostic in-house strategy is recommended by current guidelines, also for low-risk patients . The excess ED admissions incur costs of more than 10 billion dollars per year .
The HEART Pathway accelerated diagnostic protocol (ADP) provides test ordering and disposition decision support to ED practitioners and personalized care planning for patients with acute chest pain, designed to identify low-risk ED patients for early discharge without stress testing or angiography. The main difference between standard risk stratification and the HEART Pathway, is that the latter, considers such patients without troponin elevations at 0 or 3 hours to be at low-risk and eligible for early discharge.
This study assessed the safety and effectiveness of the HEART Pathway ADP by comparing risk stratification of ED patients with acute chest pain before and after implementation of this tool .
Eligible patients in this study were >21 years old and admitted to the ED due to a possible ACS, with chest pain as their main symptom and at least one troponin ordered. Patients with evidence of ST-segment elevation myocardial infarction (STEMI) on electrocardiography (ECG) were excluded, leaving a study population of 8,747 patients. The primary effectiveness outcome was hospitalization rate at 30 days.
- Of 4761 patients in the post-implementation cohort, the HEART Pathway identified 30.7% as low-risk, and 53.2% as non-low-risk patients. 7.0% had low-risk HEAR scores (History, ECG, Age, en Risicofactor score), but lacked serial troponin measurements and 9.2% had an incomplete or no HEAR score.
- Out of low-risk patients, 0.4% (6/4761, 95%CI: 0.2-0.9%) experienced death or myocardial infarction (MI) from index through 30 days.
- The use of the HEART Pathway was associated with increased detection of index visit MIs (6.6% in post-implementation cohort vs. 5.7% in pre-implementation cohort, ORadj: 1.36; 95%CI: 1.12-1.65).
- Index visits deaths occurred in 0.3% (15/4761) and 0.2% (7/3713) of patients in the post-implementation and pre-implementation cohorts, respectively (ORadj: 2.01, 95%CI: 0.79-5.10).
- During the 30 days follow-up (excluding the index visit), death or MI rates were similar in the two cohorts (post: 1.1% and pre: 1.3%, ORadj: 0.88, 95%CI: 0.58-1.33).
- Following HEART Pathway implementation, hospitalizations from index visit through 30 days were decreased by 6% (from 61.6% to 55.6%, 95%CI: 3.9-8.1%) with an ORadj of 0.79 (95%CI: 0.71-0.87), and early discharge increased by 5.6% (43.0% vs. 37.4%, 95%CI: 3.4-7.6%) with an ORadj of 1.24 (95%CI: 1.12-1.37).
- Stress testing and angiography from index visit through 30 days decreased by 3.8% (30.7% vs. 34.5%, 95%CI: 1.8% - 5.8%) with an ORadj of 0.89 (95%CI: 0.81-0.99), and median index visit length of stay decreased by 2.1 hours (15.5 hours vs. 17.6 hours, P=0.003). Median ED length of stay was similar in both cohorts (4.0 hours vs. 3.6 hours, P=0.15).
The HEART Pathway ADP is safe and effective at increasing early ED discharges and decreasing hospitalizations, stress testing, and index visit length of stay in patients with acute chest pain. These results may imply that stress tests or cardiac imaging should no longer be recommended for most low-risk patients, and support the use of the HEART Pathway ADP to stratify risk of patients with a suspected ACS during the acute phase.