Cardiology/original research
HEART Pathway Implementation Safely Reduces Hospitalizations at One Year in Patients With Acute Chest Pain

Presented at the American Heart Association Scientific Session 2019, November 2019, Philadelphia, PA.
https://doi.org/10.1016/j.annemergmed.2020.05.035Get rights and content

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.

Introduction

The evaluation of patients presenting to the emergency department (ED) with possible acute coronary syndrome in the United States is heterogeneous, inefficient, and costly.1, 2, 3 Greater than 50% of the 8 to 10 million patients presenting annually to the ED for chest pain are hospitalized or observed for lengthy evaluations with serial cardiac biomarker and objective cardiac testing (stress testing or coronary angiography).4 However, less than 10% of these patients ultimately receive a diagnosis of acute coronary syndrome, and this inefficient care costs an estimated $10 to 13 billion annually.5, 6, 7, 8

Editor’s Capsule Summary

What is already known on this topic

Many emergency departments (EDs) use standardized approaches to safely discharge low-risk chest pain patients with guideline-recommended outpatient cardiac stress testing.

What question this study addressed

This 8,474-patient pre-post interrupted time series measured the effect of the HEART Pathway integration on safely discharging low-risk chest pain patients without outpatient cardiac testing.

What this study adds to our knowledge

Although limited by 16% missing outcome data, the HEART Pathway performed reasonably well at identifying patients at low risk for 1-year adverse outcomes and was associated with decreased hospitalizations.

How this is relevant to clinical practice

This article provides further support that not all low-risk chest pain patients need outpatient stress testing. Guideline revisions should advocate selective, not universal, testing.

Frequent hospitalizations for objective cardiac testing in patients with chest pain are driven in large part by studies demonstrating that such testing modalities have a high negative predictive value (95% to 99%) for acute coronary syndrome at 1 year.9, 10, 11, 12, 13 These studies are the foundation of Class IIa American College of Cardiology/American Heart Association guideline recommendations, which state that patients with chest pain should have objective cardiac testing even if they are at low risk for acute coronary syndrome.14,15 However, objective cardiac testing in low-risk patients is associated with a substantial number of false-positive and nondiagnostic test results, without clear evidence of improved health outcomes.3,16, 17, 18, 19 Thus, new risk-stratification strategies, which avoid hospitalizations and objective cardiac testing while maintaining a high 1-year negative predictive value for adverse cardiac events, are needed.

The HEART (History, ECG, Age, Risk Factors, Troponin) Pathway is an accelerated diagnostic protocol designed to identify low-risk ED patients who can be safely discharged early from the ED without objective cardiac testing.20,21 The HEART Pathway has demonstrated safety and effectiveness at 30 days.22,23 However, there are limited data regarding its safety and effectiveness at 1 year. To address this evidence gap, we completed a preplanned 1-year analysis of the multisite HEART Pathway Implementation study. We hypothesized that the HEART Pathway will decrease hospitalizations and objective cardiac testing at 1 year while achieving a high negative predictive value for death and myocardial infarction.

Section snippets

Study Design and Setting

A preplanned 1-year analysis of the HEART Pathway Implementation study was conducted. Participants were prospectively accrued under a waiver of informed consent from November 2013 to January 2016. This study was institutional review board approved. Methods of the HEART Pathway Implementation study, a prospective pre-post interrupted time series, have been previously published.20,24 The study was conducted at 3 hospitals in North Carolina: Davie Medical Center, with approximately 12,000 annual

Characteristics of Study Subjects

A total of 8,474 patients were accrued during the study period (Figure 2). The cohort was 34.0% nonwhite (2,884/8,474) and 53.6% women (4,541/8,474), with a median age of 54 years. Characteristic of the cohort are summarized in Table 1. The 1-year death and myocardial infarction rate of the cohort was 11.9% and revascularization occurred in 4.7% of patients.

Main Results

The HEART Pathway identified 30.7% (1,461/4,761) of the postimplementation cohort as low risk; 53.2% (2,531/4,761) were nonlow risk,

Limitations

Our study design has limitations. Secular trends and provider maturation effects are potential threats to the validity of our results. However, as previously reported in the primary analysis, event rates were fairly consistent over time. The use of our electronic health record to collect events may have decreased event rates compared with traditional methods of follow-up, but the electronic health record data were supplemented with death index and claims data to address this. The 3 sites in

Discussion

Results of this preplanned 1-year analysis of the multisite HEART Pathway Implementation study demonstrate that the HEART Pathway decreases 1-year hospitalizations and objective cardiac testing while achieving a high negative predictive value for adverse cardiac events. The HEART Pathway classified 31% of ED patients with acute chest pain as low risk, with a negative predictive value of 97.5% for 1-year death or myocardial infarction. Although there is some consensus that an accelerated

References (39)

  • S.A. Mahler et al.

    Identifying patients for early discharge: performance of decision rules among patients with acute chest pain

    Int J Cardiol

    (2013)
  • S.A. Mahler et al.

    Use of the HEART Pathway with high sensitivity cardiac troponins: a secondary analysis

    Clin Biochem

    (2017)
  • K.G. Moons et al.

    Using the outcome for imputation of missing predictor values was preferred

    J Clin Epidemiol

    (2006)
  • D.L. Simel et al.

    Likelihood ratios with confidence: sample size estimation for diagnostic test studies

    J Clin Epidemiol

    (1991)
  • K.C. Safavi et al.

    Hospital variation in the use of noninvasive cardiac imaging and its association with downstream testing, interventions, and outcomes

    JAMA Intern Med

    (2014)
  • A.J. Foy et al.

    Comparative effectiveness of diagnostic testing strategies in emergency department patients with chest pain: an analysis of downstream testing, interventions, and outcomes

    JAMA Intern Med

    (2015)
  • A.T. Sandhu et al.

    Cardiovascular testing and clinical outcomes in emergency department patients with chest pain

    JAMA Intern Med

    (2017)
  • J.H. Pope et al.

    Missed diagnoses of acute cardiac ischemia in the emergency department

    N Engl J Med

    (2000)
  • V.L. Roger et al.

    Heart disease and stroke statistics—2011 update: a report from the American Heart Association

    Circulation

    (2011)
  • Cited by (0)

    Please see page 556 for the Editor’s Capsule Summary of this article.

    Supervising editor: Tyler W. Barrett, MD, MSCI. Specific detailed information about possible conflict of interest for individual editors is available at https://www.annemergmed.com/editors.

    Author contributions: JPS, DMH, BCH, CDM, and SAM were responsible for study concept and design. JPS, BCH, CDM, and SAM were responsible for acquisition of data. JPS, ACS, KML, and SAM were responsible for analysis and interpretation of data. JPS, ACS, KML, CDM, and SAM were responsible for drafting the article. All authors were responsible for critical revision of the article. ACS and KML provided statistical expertise. SAM was responsible for acquisition of funding. JPS takes responsibility for the paper as a whole.

    All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). This project was funded by the Donaghue Foundation and the Association of American Medical Colleges. Dr. Stopyra receives research funding from Abbott Laboratories and Roche Diagnostics. Dr. Miller receives research funding and support from Siemens, Abbott Point of Care, and 1 R01 HL118263. Dr. Mahler receives research funding from Abbott Laboratories, Roche Diagnostics, Siemens, Ortho Clinical Diagnostics, Creavo Medical Technologies, Patient-Centered Outcomes Research Institute, Agency for Healthcare Research and Quality, and National Heart Lung and Blood Institute (1 R01 HL118263-01, L30 HL120008), and is the Chief Medical Officer for Impathiq Inc.

    Trial registration number: NCT02056964

    Readers: click on the link to go directly to a survey in which you can provide feedback to Annals on this particular article.

    A podcast for this article is available at www.annemergmed.com.

    View full text