Henry Ford HEART Score Randomized Trial

Frisoli, Tiberio; Nowak, Richard M.; Evans, Kaleigh L.; Harrison, Michael F.; Alani, Maath; Varghese, Saira; Rahman, Muhammad Imadur; Noll, Samantha; Flannery, Katherine R.; Michaels, Alexander; Tabaku, Mishel; Jacobsen, Gordon; McCord, James

doi:10.1161/circoutcomes.117.003617

Cited by 27 publications

(10 citation statements)

References 30 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Among patients without STEMI, known coronary disease (CAD), or acute ischemic ECG changes, providers answered additional flow sheet questions to determine a History, ECG, Age, and Risk factor score (HEAR score); calculated based on the HEART Pathway trial algorithm (Impathiq Inc., Raleigh, NC). 22 Troponin measurements were incorporated through a direct link to laboratory results. The HEART Pathway risk assessment was automatically calculated based on the HEAR score and 0 and 3-hour troponin measures.…”

Section: Methodsmentioning

confidence: 99%

Safely Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge

et al. 2018

View full text Add to dashboard Cite

Background: The HEART Pathway is an accelerated diagnostic protocol (ADP) designed to identify low-risk Emergency Department (ED) patients with chest pain for early discharge without stress testing or angiography. The objective of this study was to determine whether implementation of the HEART Pathway is safe (30 day death and myocardial infarction rate <1% in low-risk patients) and effective (reduces 30 day hospitalizations) in ED patients with possible acute coronary syndrome (ACS). Methods: A prospective pre/post study was conducted at three US sites among 8,474 adult ED patients with possible ACS. Patients included were ≥21 years old, investigated for possible ACS, and had no evidence of ST-segment elevation myocardial infarction on electrocardiography. Accrual occurred for 12 months before and after HEART Pathway implementation from November 2013- January 2016. The HEART Pathway ADP was integrated into each site’s electronic health record as an interactive clinical decision support tool. Following ADP integration, ED providers prospectively utilized the HEART Pathway to identify patients with possible ACS as low-risk (appropriate for early discharge without stress testing or angiography) or non-low-risk (appropriate for further in-hospital evaluation). The primary safety and effectiveness outcomes, death and myocardial infarction (MI) and hospitalization rates at 30 days, were determined from health records, insurance claims, and death index data. Results: Pre- and post-implementation cohorts included 3713 and 4761 patients, respectively. The HEART Pathway identified 30.7% as low-risk; 0.4% of these patients experienced death or MI within 30 days. Hospitalization at 30 days was reduced by 6% in the post- vs pre-implementation cohort (55.6% vs 61.6%; aOR: 0.79, 95%CI: 0.71–0.87). During the index visit more MIs were detected in the post-implementation cohort (6.6% vs 5.7%; aOR: 1.36, 95%CI: 1.12–1.65). Rates of death or MI during follow-up were similar (1.1% vs 1.3%; aOR: 0.88, 95% CI: 0.58–1.33). Conclusions: HEART Pathway implementation was associated with decreased hospitalizations, increased identification of index visit MIs, and a very low death and MI rate among low-risk patients. These findings support use of the HEART Pathway to identify low-risk patients that can be safely discharged without stress testing or angiography. Clinical Trial Registration: clinicaltrials.gov Identifier: NCT02056964

show abstract

Section: Methodsmentioning

confidence: 99%

Safely Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge

et al. 2018

View full text Add to dashboard Cite

show abstract

“…The two randomized studies that indirectly addressed this question in a similar but not identical population of ED chest pain patients did not demonstrate a reduction in significant cardiac events (described above), including MACE, at 30 days. 48,49 The multicenter, retrospective cohort study evaluating the incidence of MACE at 30 days in patients who completed an outpatient stress test did not demonstrate any associated benefit of stress testing within 3 days, nor within 30 days, compared with not undergoing a stress test at all. 50 Harms and burden…”

Section: Benefitsmentioning

confidence: 97%

“…An additional literature search for indirect evidence focusing on stress testing for adult ED patients with non-high-risk chest pain, not necessarily recurrent and without recent testing specified, yielded two randomized studies. 48,49 Neither of these two studies used MACE as a primary outcome but did report on a similar, more broadly defined outcome termed "cardiac events" at 30 days. An additional literature search for indirect evidence focusing on outpatient stress testing for adult patients discharged from the ED after a visit for chest pain, not necessarily recurrent and without recent testing specified, yielded one multicenter, retrospective study.…”

Section: Summary Of the Evidencementioning

confidence: 99%

Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low‐risk chest pain in the emergency department

Musey

Bellolio

Upadhye

et al. 2021

Academic Emergency Medicine

View full text Add to dashboard Cite

This first Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE‐1) from the Society for Academic Emergency Medicine is on the topic: Recurrent, Low‐risk Chest Pain in the Emergency Department. The multidisciplinary guideline panel used The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding eight priority questions for adult patients with recurrent, low‐risk chest pain and have derived the following evidence based recommendations: (1) for those >3 h chest pain duration we suggest a single, high‐sensitivity troponin below a validated threshold to reasonably exclude acute coronary syndrome (ACS) within 30 days; (2) for those with a normal stress test within the previous 12 months, we do not recommend repeat routine stress testing as a means to decrease rates of major adverse cardiac events at 30 days; (3) insufficient evidence to recommend hospitalization (either standard inpatient admission or observation stay) versus discharge as a strategy to mitigate major adverse cardiac events within 30 days; (4) for those with non‐obstructive (<50% stenosis) coronary artery disease (CAD) on prior angiography within 5 years, we suggest referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (5) for those with no occlusive CAD (0% stenosis) on prior angiography within 5 years, we recommend referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (6) for those with a prior coronary computed tomographic angiography within the past 2 years with no coronary stenosis, we suggest no further diagnostic testing other than a single, normal high‐sensitivity troponin below a validated threshold to exclude ACS within that 2 year time frame; (7) we suggest the use of depression and anxiety screening tools as these might have an effect on healthcare use and return emergency department (ED) visits; and (8) we suggest referral for anxiety or depression management, as this might have an impact on healthcare use and return ED visits.

show abstract

“…The value-added by cardiologist phone-consultation may be in the facilitation of ED testing in a population for whom that option would not be considered otherwise. If demonstrated in a larger prospective cohort, a strategy of ED testing guided by cardiology phone-consultation in selected high-risk HEART pathway patients could safely result in less time spent in the hospital and reductions in the cost of care, analogous to the strategy of early discharge for low-risk HEART pathway patients [6].…”

Section: Discussionmentioning

confidence: 99%

Potential impact of cardiology phone-consultation for patients risk-stratified by the HEART pathway

et al. 2019

View full text Add to dashboard Cite

ObjectiveBedside consultation by cardiologists may facilitate safe discharge of selected patients from the emergency department (ED) even when admission is recommended by the History, Electrocardiogram, Age, Risk factors, Troponin (HEART) pathway. If bedside evaluation is unavailable, phone consultation between emergency physicians and cardiologists would be most impactful if the resultant disposition is discordant with the HEART pathway. We therefore evaluate discordance between actual disposition and that suggested by the HEART pathway in patients presenting to the ED with chest pain for whom cardiology consultation occurred exclusively by phone and to assess the impact of phone-consultation on disposition.MethodsWe performed a single-center, retrospective study of adults presenting to the ED with chest pain whose emergency physician had a phone consultation with a cardiologist. Actual disposition was abstracted from the medical record. HEART pathway category (low-risk, discharge; high-risk, admit) was derived from ED documentation. For discharged patients, major adverse cardiac events were assessed at 30 days by chart review and phone follow-up.ResultsFor the 170 patients that had cardiologist phone consultation, discordance between actual disposition and the HEART pathway was 17%. The HEART pathway recommended admission for nearly 80% of discharged patients. Following cardiologist phone-consultation, 10% of high-risk patients were discharged, with the majority having undergone a functional study recommended by the cardiologist. At 30 days, discharged patients had experienced no episodes of major adverse cardiac events or rehospitalization for cardiac reasons.ConclusionFor patients presenting to the ED with chest pain, cardiology phone-consultation has the potential to safely impact disposition, primarily by facilitating functional testing in high-risk individuals.

show abstract

Henry Ford HEART Score Randomized Trial

Abstract: URL: http://www.clinicaltrials.gov. Unique identifier: NCT03058120.

Cited by 27 publications

References 30 publications

Safely Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge

Safely Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge

Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low‐risk chest pain in the emergency department

Potential impact of cardiology phone-consultation for patients risk-stratified by the HEART pathway

Contact Info

Product

Resources

About