HEART PATHWAY for Cardiac Risk

Practice Changer: The HEART Pathway is a simple cardiac risk assessment tool that is designed for use in the ED.  It’s safe and effective at classifying patients as low risk for outpatient evaluation of cardiac disease while also decreasing length of stay and cardiac testing.  



Background:

The HEART score was described in the Netherlands in 2008  and retrospectively validated initially in a European Cohort, then in the United States at Wake Forest University where they retrospectively found the rates of MACE (Major Adverse Cardiac Events) ** at 6 weeks in patients with HEART scores of 0-3 to be 0.6% (5/904 pts).  A prospective validation study confirmed the HEART score’s utility (see below).

July 2

It was noted in the retrospective US study (above) that the addition of negative serial biomarkers to the HEART score decreased risk to 0% MACE at 6 weeks.  Subsequently a 0 and 3 hour troponin has been added to the HEART score and termed the “HEART Pathway.”  This pathway was found to have over 99% sensitivity for MACE as a secondary retrospective outcome of the 1000+ patients in the MIDAS trial (below).  Earlier this year a prospective trial to describe benefits of using HEART was performed (below) showing no missed MACE and decreased length of stay and use of stress testing.

August 1

Below are:

  1.  The Prospective HEART Score validation article
  2. The HEART Pathway Retrospective Analysis
  3. The Prospective HEART  trial

1. Prospective validation study of the HEART Score.


A prospective validation of the HEART score for chest pain patients at the emergency department

— International Journal of Cardiology 2013

Study Design: Prospective cohort study

Population: All Patients presenting to 10 EDs in the Netherlands with Chest Pain.

Inclusion Criterion: All Chest Pain Patients. No age restrictions. Dyspnea and Palpitations were excluded. STEMIs were generally taken directly to the cath lab, so mostly excluded from analysis.

Data: HEART score, TIMI, and GRACE score was calculated for each patient.

July 2

ECG is the one factor that probably needs definition

  • 1 point = bundle branch block, LVH, repolarisation abnormalities from digoxin or other repolarisation abnormalities.
  • 2 points = any ST elevation or ST depression without BBB or LVH.

Risk Factors:

  • 1 Risk Factor: Treated Diabetes, Smoking, Diagnosed Hypertension, Diagnosed Hyperlipidemia, Family History of CAD, and OBESITY
  • 2 points are given for category if there is a: history of CAD, revascularisation, stroke, peripheral vascular disease

Primary End Point: Major Adverse Cardiac Event (MACE) at 6 weeks.

        MACE =AMI, PCI, CABG, coronary angiography revealing procedurally correctable stenosis managed conservatively, and death due to any cause.

Follow Up: Hospital Records or if not available, patients or PCPs were contacted

Results: 2440 patients with Chest Pain of which 45 were lost to follow up.

  • 407 patients with MACE

Comparison?

Rates of MACE at 6 weeks for Low Risk scores:

  • HEART score 0-3 (36.4% of study population)  = 1.7%
  • TIMI 0 -1 (34% of study population) = 2.8%
  • GRACE 0-60 (14% of study population) = 2.9%

August 6

Conclusion: HEART score for chest pain patients at the emergency department provides the clinician with a quick and reliable predictor of outcome shortly after arrival of the patient, without computer-required calculating.


2. HEART PATHWAY – What about the addition of serial troponins?


Identifying Patients for Early Discharge: Performance of Decision Rules Among Patients with Acute Chest Pain

– Int J Cardiol 2014

Study Design: Re-analysis of Prospective Cohort acquired for MIDAS study

Population: 1005 Patients >21 years old presenting to 18 US EDs with symptoms of Acute Coronary Sydrome

Comparison:

  1. Unstructured Analysis  (Essentially Gestalt)
  2. HEART score
  3. NACPR score by itself and with troponins at 0 and 3 hours.

Outcomes:

  1. % classified as low risk  and discharged from the ED
  2. ACS within 30 days (AMI and Unstable Angina shown on catheterization included)

Results: 

% Low Risk Sensitivity for MACE
Gestalt + Trop 13.5% 98%
HEART Score + Trop 20%

99.1%

NACPR + Trop 4.4% 100%

My Conclusions: The HEART score with 0 and 3 hour serial troponin identified more people for discharge and did a better job identifying high risk individuals than clinical gestalt.  It also decreases the miss rate to <1%.


3. Prospective Study of Usual Care vs HEART Pathway


The HEART Pathway Randomized Trial: Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge

Circ Cardiovasc Qual Outcomes

Study: Prospective Randomized controlled trial of ED patients at Wake Forest University Medical Center

Population: Patients >21 years old with a troponin and EKG to rule out ACS,

Exclusions: STEMIs, Hypotension, non-cardiac source of symptoms discovered in ED.

Intervention: HEART score with a troponin at 0 and 3 hours. If low risk, they were discharged to home with PCP follow up within 1 week.

August 1

Control: Usual Care by ACC/AHA guidelines.  Typically involving serial biomarkers  and objective cardiac testing before discharge.

Primary Outcome: Objective Cardiac Testing Rates within 30 days, Hospital Length of Stay

Secondary Outcome: MACE at 30 days

Results: 282 patients randomized to two groups, 96% follow up at 30 days, no deaths in social security registry

Primary Outcome:

Decreased Objective Cardiac Testing by 12.1% at 30 days

Secondary Outcome:

No MACE in either low risk group at 30 days

Early Discharge increased with HEART by 21%, (would have been 29% except for protocol violations)

HEART Pathway decreased average patient’s LOS by 12 hours

August 2

Conclusions: Compared to usual ACC/AHA care, use of the HEART Pathway decreases utilization of health care resources.


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