HEART tool reduces cardiac testing in patients with acute chest pain

HEART might offer a way to discharge low-risk chest pain patients early and reduce objective cardiac testing, according to findings published March 3. While early discharge with no increase in major adverse events would be a coup, some are not convinced that reducing cardiac testing rates overall is feasible.

The HEART (History, Electrocardiogram, Age, Risk factors, Troponin) Pathway model was compared with usual care in patients presenting at the emergency department with chest pain. Researchers found that using the HEART Pathway model, early discharge was increased by 21.3 percent with no 30-day major adverse cardiac events (MACE) reported.

The randomized, controlled trial enrolled 282 chest pain patients admitted to a single emergency department. Simon A. Mahler, MD, MS, assistant professor of emergency medicine at Wake Forest Baptist Medical Center in Winston-Salem, N.C., and colleagues reviewed how use of HEART could reduce objective cardiac testing by identifying patients who needed it least. They also analyzed outcomes, including length of stay, early discharge and MACE at 30 days.

They found objective cardiac testing at 30 days was reduced by 12.1 percent among patients in the HEART Pathway group. Length of stay for HEART Pathway patients was 12 hours shorter. Physicians identified 39.7 percent of HEART Pathway patients for early discharge.

“Results of this trial demonstrate that the HEART Pathway substantively reduces healthcare utilization among patients with symptoms related to ACS [acute coronary syndrome],” they wrote.

While reduced healthcare utilization is part of the goal of many similar assessment tools, a commentary writer warned that some focuses, such as reduction of overall objective cardiac testing, may be a hard sell and may only delay—not prevent—testing among patients who may be at low risk but suspected of acute coronary syndrome. 

“Clinically, the leap of faith required for this outcome measure is sizable. Even in Canada, where physicians are far less likely to request objective testing before ED [emergency department] discharge, we suspect that removing the safeguard of subsequent outpatient objective cardiac testing on patients with a reasonable presentation for acute coronary syndrome is not likely to gain widespread traction,” wrote Clare L Atzema, MD, MSc, of the Sunnybrook Health Sciences Centre in Toronto, and colleagues. They  reminded readers that according to one study, 17 percent of acute coronary syndromes were identified through objective testing.

Reduction, specifically, of inappropriate coronary testing, is a widespread goal that programs such as Choosing Wisely and others work toward, but an overall reduction in coronary testing may do more harm than good, they wrote. Beyond 30 days, patients also may get tested as their primary care physicians address the cause of a patient’s chest pain.

Still, Atzema et al found the other results by Mahler et al promising, although “[i]t is clear that researchers are getting closer to a clinically acceptable tool for the safe early disposition of patients with chest pain from ED, but no instrument seems ready for prime-time yet.” 

The study and editorial were published online in Circulation: Cardiovascular Quality and Outcomes.