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, 8Editor’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.