Chest Pain Identified as Low Risk for Acute Coronary Syndrome (ACS). Can a HEART Score Pathway Identify More Patients for Early Safe Discharge than the Current TIMI Score Pathway?

Abstract

Aim: We compared our current TIMI pathway with a HEART pathway in patients with undifferentiated chest pain in terms of adverse cardiac events and number safely identified as low risk. We audited our management of low risk patients. Method: We screened consecutive chest pain presentations to ED and ADU in 2 Auckland hospitals. We included 525 patients with TIMI score 0 or 1, and 0 and 2 hours negative contemporary Troponin I. TIMI score and chest pain history was recorded by admitting physician. HEART score and endpoints were captured from electronic data, GP and patient phone calls. The primary endpoint was Adverse Cardiac Events (ACE) within 3 months. The secondary endpoint was measurement of length of stay and further cardiac testing. Results: 398 had HEART score 0-3 and negative serial TI (low risk HEART) with adverse cardiac event rate of 0.5% (95% CI 0.14 – 1.81). 366 patients had TIMI 0 and negative TI (low risk TIMI) with event rate of 1.1% (0.4 – 2.8). The HEART pathway identified 9% more patients as low risk. 56% of our TIMI 0 cohort was referred for exercise treadmill test, 12% for CTCA and 1.6% for coronary angiogram. Average LOS was 8.69 hours Conclusion: The HEART pathway safely identifies significantly more patients as low risk compared to our TIMI pathway. WDHB do further cardiac investigation in the majority of our low risk patients, despite an acceptably low miss rate for cardiac events. We can reduce costs significantly by incorporating HEART score in the pathway and by re-education of our physicians.