Efficacy Evaluation of the HEART Pathway in Emergency Department Patients With Acute Chest Pain
Efficacy Evaluation of the HEART Pathway in Emergency Department Patients With Acute Chest Pain
Our research will examine a chest pain care strategy, called the HEART pathway, which is
 designed to correctly identify Emergency Department patients at high-risk for cardiovascular
 events, likely to benefit from further testing, and patients at very-low-risk for
 cardiovascular events, who may be safely discharged home. By using an individual's risk
 assessment to determining testing, we hope to improve the quality and efficiency of the care
 delivered to Emergency Department patients with chest pain. Our study will determine if the
 HEART pathway, which combines a clinical decision rule, the HEART score, and two serial
 troponin measurements, will reduce stress testing and cardiovascular imaging, decrease
 hospital length of stay, and reduce cost compared to usual care, while maintaining safety.
Approximately 8-10 million patients complaining of chest pain present to an Emergency
 Department (ED) annually in the United States. The total cost of chest pain evaluations has
 been estimated at $5-10 billion annually, yet only 10% of these patients are ultimately
 diagnosed with an acute coronary syndrome. American College of Cardiology/ American Heart
 Association (ACC/AHA) guidelines recommend that patients at low-risk for acute coronary
 syndrome should receive serial cardiac markers followed by objective cardiac testing (stress
 testing or cardiac imaging). However, many have questioned the value of objective cardiac
 testing in all low-risk patients.Cardiac testing for all patients at low-risk for acute
 coronary syndrome (ACS) is not sustainable from a healthcare quality or economic perspective.
 In addition to increasing costs, objective cardiac testing is associated with a substantial
 number of false positive and non-diagnostic tests, which lead to additional unnecessary and
 often invasive procedures.

 Implementation of accurate risk stratification care pathways designed to eliminate
 unnecessary cardiac testing could improve the efficiency and quality of care by decreasing
 false positive/non-diagnostic testing, radiation, and costs. The HEART pathway, which
 combines a clinical decision rule, the HEART score, and two serial troponin measurements, is
 a recently developed care pathway designed to identify chest pain patients for early
 discharge without objective testing.

 Primary Hypothesis: The HEART Pathway, when compared to usual care, will reduce 30 day
 objective cardiac testing, hospital length of stay, and cost, while maintaining patient
 safety.

 Methods: Participants (n=282) at risk for ACS will be recruited into a clinical trial from
 Wake Forest Baptist Medical Center (WFBMC) ED. Patients will be equally randomized to HEART
 Pathway or Usual Care. HEART Pathway participant's treating physician will follow HEART
 Pathway guidelines for identifying patients to be admitted to the hospital or observation
 unit for cardiac testing or to be discharged home without testing. Usual Care participant's
 treating physicians will decide whether the patients should be discharged home or admitted to
 the hospital or observation unit based on ACC/AHA guidelines without using the HEART pathway.
Inclusion Criteria:

 -  Age greater than or equal to 21 years

 -  Chest discomfort or other symptoms consistent with possible ACS

 -  The treating physician feels the patient could be discharged home if cardiac disease
 was excluded

 Exclusion Criteria:

 -  New ST-segment elevation in contiguous leads on any electrocardiogram (>/= 1 mV)

 -  Unstable vitals signs: symptomatic hypotension at the time of enrollment (systolic <
 90 mm Hg), tachycardia (HR>120), bradycardia (HR<40), and hypoxemia (<90%
 pulse-oximetry on room air or normal home oxygen flow rate)

 -  Terminal diagnosis with life expectancy less than 1 year

 -  A non-cardiac medical, surgical, or psychiatric illness determined by the provider to
 require admission, increase risk of objective cardiac testing, or prevent immediate
 discharge following negative testing.

 -  Prior enrollment

 -  Incapacity or unwillingness to provide consent and comply with study procedures

 -  Non-English speaking

 Sub-study I & II

 Inclusion Criteria:

 -  ED attending physicians

 Exclusion Criteria:

 -  ED attending physicians who decline to participate