HEART_Pathway_for_Early_Discharge_in_Acute_Chest_Pain_guideline v.1
The HEART Pathway is a decision aid designed to identify emergency department patients with acute chest pain for early discharge. HEART Pathway Score is calculated with the addition of the selected points: History (e.g. Retrosternal pain, pressure, radiation to jaw/left shoulder/arms, duration 5–15 min, initiated by exercise/cold/emotion, perspiration, nausea/vomiting, reaction on nitrates within mins, patient recognizes symptoms. Low risk features of chest pain include: well localized, sharp, non-exertional, no diaphoresis, no nausea or vomiting, and reproducible with palpation): Slightly suspicious=0, Moderately suspicious=1, Highly suspicious=2. EKG: Normal=0, Non-specific repolarization disturbance=1(LBBB, typical changes suggesting LVH, repolarization disorders suggesting digoxin, unchanged known repolarization disorder), Significant ST depression=2(Significant ST-segment depression or elevation without LBBB, LVH, or digoxin.). Age (years): <45=0, 45-64=1, ≥65=2. Risk factors: No known risk factors=0, 1-2 risk factors= 1, ≥3 risk factors or history of atherosclerotic disease=2(HTN, hypercholesterolemia, DM, obesity (BMI >30 kg/m²), smoking (current, or smoking cessation ≤3 mo), positive family history (parent or sibling with CVD before age 65)). Initial troponin: ≤normal limit=0, 1-3x normal limit=1, >3x normal limit=2(Use local assays and corresponding cutoffs). Interpretation: HEART Score ≤3, Initial troponin 0 point= Low Risk (0.9-1.7% 30-day MACE) and Recommendation is to repeat troponin at 3 hours and if negative, discharge home with outpatient follow-up. HEART Score ≤3, Initial troponin 1-2 points= High Risk (12-65% 30-day MACE) and Recommendation is Cardiology consultation and admission recommended. Further testing indicated. HEART Score ≥4, Initial troponin 0 point= High Risk (12-65% 30-day MACE) and Recommendation is to Admit to hospital or observation. Further testing indicated. HEART Score ≥4, Initial troponin 1-2 points= High Risk (12-65% 30-day MACE) and Recommendation is Cardiology consultation and admission recommended. Further testing indicated.
Identifies emergency department patients with acute chest pain for early discharge.
Use in patients ≥21 years old presenting with symptoms suggestive of ACS.
Do not se in patients ≤21 years old. Do not use if new ST-segment elevation ≥1 mm or other new EKG changes, hypotension, life expectancy less than 1 year, or noncardiac medical/surgical/psychiatric illness determined by the provider to require admission.
Mahler SA, Riley RF, Hiestand BC, Russell GB, Hoekstra JW, Lefebvre CW, Nicks BA, Cline DM, Askew KL, Elliott SB, Herrington DM. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circulation: Cardiovascular Quality and Outcomes. 2015 Mar;8(2):195-203. Poldervaart JM, Reitsma JB, Backus BE, Koffijberg H, Veldkamp RF, Monique E, Appelman Y, Mannaerts HF, van Dantzig JM, Van Den Heuvel M, El Farissi M. Effect of using the HEART score in patients with chest pain in the emergency department: a stepped-wedge, cluster randomized trial. Annals of internal medicine. 2017 May 16;166(10):689-97. Riley RF, Miller CD, Russell GB, Harper EN, Hiestand BC, Hoekstra JW, Lefebvre CW, Nicks BA, Cline DM, Askew KL, Mahler SA. Cost analysis of the History, ECG, Age, Risk factors, and initial Troponin (HEART) Pathway randomized control trial. The American journal of emergency medicine. 2017 Jan 1;35(1):77-81. Mahler SA, Stopyra JP, Apple FS, Riley RF, Russell GB, Hiestand BC, Hoekstra JW, Lefebvre CW, Nicks BA, Cline DM, Askew KL. Use of the HEART Pathway with high sensitivity cardiac troponins: a secondary analysis. Clinical biochemistry. 2017 May 1;50(7-8):401-7.
OBSERVATION.heart_pathway_for_early_discharge_in_acute_chest_pain.v0, EVALUATION.heart_pathway_for_early_discharge_in_acute_chest_pain.v0
