Objectives: The History Electrocardiogram Age Risk factor Troponin (HEART) Pathway stratifies patients with acute chest pain into low- and non-low risk groups. Low-risk patients may be discharged from the emergency department (ED) without objective cardiac testing (OCT). However, some clinicians obtain OCT despite a low-risk assessment. The objectives of this study were to assess the frequency of OCT in low-risk HEART Pathway patients and determine patient factors associated with receiving OCT.
Methods: A retrospective study of ED patients with chest pain and a low-risk HEART Pathway assessment was conducted from 1/2017-7/2018. Low-risk was defined as a HEAR score ≤3, no ischemic ECG changes, no known coronary artery disease, and no elevated troponins. Electronic health records were queried to collect HEART Pathway assessments and determine OCT results. We defined OCT as any stress test or coronary angiography during the index visit. Fisher’s exact and Mann-Whitney U testing were used for univariate analysis and logistic regression was used to compare patient characteristics between OCT vs no-OCT groups<
Results: During the study period there were 2,074 patients with low-risk chest pain. OCT was performed on 4.1% (84/2074). Patients receiving OCT were more likely to be older (52.6, 95%CI 50.3-54.9) compared to the no-OCT group (48.1, 95%CI 47.5-48.6). White patients were more likely to receive OCT than non-white patients (5.0% vs 3.0%, p = 0.025). HEAR scores were significantly higher in the OCT group (p < 0.001). OCT did not differ by sex (males 5.0% vs 3.4%, p = 0.07). The HEAR score (OR 2.2, 95%CI 1.5-3.2) and white race (OR 1.6, 95%CI 1.0-2.5) remained significant when adjusting for age and sex. Of the 84 low-risk patients who received OCT, 8.3% (7/84) had indeterminate studies and 2.6% (2/84) had positive studies. Among these 2 patients, 1 had a false positive stress test and 1 had coronary disease on angiography with subsequent elective CABG.
Conclusion: OCT among patients with a low-risk HEART Pathway assessment was uncommon, but was more likely to occur in older patients, white patients, or those with higher HEAR scores. Among the low-risk patients who received OCT, only 1 required elective intervention. These findings confirm that OCT is unnecessary in patients with low-risk HEART Pathway assessments.