HEART Pathway App: Fast Tracks Chest Pain Patients Using Evidence Based Accelerated Protocol

Chest pain patients account for nearly 10 million ER visits each year with a cost of over $10 billion. These costs are due to overzealous diagnostic testing, time and use of healthcare resources. Less than 10% of patients presenting to an ER will suffer a major adverse cardiac event (MACE) in the next 30 days. Yet despite these herculean efforts and costs, 2-5% of patients with chest pain discharged from the ER experience a cardiac event. These “missed” MACE’s account for a significant proportion of malpractice claims against emergency medicine physicians. Furthermore, patients are exposed to the risks inherent with over testing including false negative, false positives and radiation exposures from nuclear stress tests and angiography. Clearly, we need a better method to evaluate chest pain patients.

The Emergency Medicine team at Wake Forest School of Medicine headed by Dr Simon Mahler, MD spearheaded the HEART study. Three studies have shown the benefits of the HEART score in the risk stratification of chest pain patients: a 2011 cohort study, a 2013 secondary analysis of the MIDAS trial and a 2015 randomized controlled trial. In the 2011 study, the investigators validated the score in over 1,100 patients presenting with chest pain and demonstrated the validity of the HEART score. When combined with troponins, the HEART score had a sensitivity and specificity of 100% and 83% respectively and decreased follow-on cardiac testing by 82%. A significant cost savings per chest pain patient has been reported form the Wake Forest group on their website.

More details about the HEART Pathway can be found in this presentation by Dr Mahler. The Pathway cannot be applied to patients with STEMI, ischemic ECG changes or coronary artery disease. The HEART pathway app takes into account a patient’s age, presenting symptoms, cardiac risk factors, and ECG changes to calculate the HEAR value which becomes a HEART value when combined with troponin testing. A score of 3 or less carries a less than 1% risk of MACE in the next 30 days. These patients can be safely discharged from the ER without further workup. Those with a score of 4 or greater carry a higher risk of MACE and need further cardiac evaluation.

Clinical Scenario

You are in clinic evaluating a 49 year old male with acute onset of left sided chest pain with associated nausea, vomiting and diaphoresis. His past medical history is significant for a BMI>30, hypertension and smoking. His initial ECG is within normal limits. Should we admit this patient for stress testing or can we discharge him from the Emergency Room? What is the likelihood that this patient’s presenting symptoms represent ACS? What is the likelihood that this patient will have an ACS event in the near future (within 30 days)? HEART Pathway will help you with these decisions! Let’s take a look at HEART Pathway in action.

Video Review

Evidence based medicine

HEART Pathway takes the data collected in Dr Mahler, et al.’s HEART trial and incorporates it into an evidence-based algorithm that can be used to fast track chest pain patients in the ER. The HEART score has been shown to decrease costs, cut down on unnecessary diagnostic testing and lead to early ER discharge for chest pain patients. It would be ideal to see it studied further and implemented on a wider scale–having the algorithm/calculator in app form will help dissemination significantly.

What providers would benefit from this App?

Students, residents, mid-levels, Emergency Medicine, Urgent Care, Internal Medicine, Family Medicine, Cardiologists and any provider who cares for chest pain patients in the ER setting.

Disclaimer: The app under review was co-developed by Dr Iltifat Husain, MD, an Emergency Medicine Physician at Wake Forest School of Medicine and the Founder and CEO of imedicalapps.com. The views expressed are those of the author(s) and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. Government.