Background: Safety and effectiveness of the History Electrocardiogram Age Risk factor Troponin (HEART) Pathway is well established. However, data comparing the HEART Pathway to clinician gestalt is limited. Thus, the objective of this study is to compare the performance of the HEART Pathway to gestalt for the detection of 30-day adverse events.
Methods: A secondary analysis of the HEART Pathway Implementation Study was conducted. This prospective pre/post study accrued adults with acute chest pain from 3 sites (10/2013-1/2016). Throughout the study, gestalt assessments were completed in real-time by treating providers. In the post-period, HEART Pathway assessments were completed by providers after their gestalt assessments. For gestalt, low-risk was defined as a low-risk assessment with no elevated troponins. Death and myocardial infarction (MI) at 30 days were determined by health records, insurance claims, and death index. Sensitivity and negative predictive value (NPV) for 30-day death and MI were calculated for gestalt and HEART Pathway and compared with Fisher exact testing. Net reclassification was calculated in patients with both gestalt and HEART Pathway assessments. The performance of gestalt was compared pre and post- HEART Pathway implementation.
Results: Gestalt and HEART Pathway were assessed on 6773 and 4986 patients, respectively. Death and MI at 30 days occurred in 5.6% (377/6773) of patients with gestalt assessments and 7.1% (356/4986) with HEART Pathway assessments. Sensitivity for 30-day death and MI was 87.5% (95%CI 84.2-90.9%) for gestalt vs 97.8% (95%CI 96.2-99.3%) for HEART Pathway (p<0.0001). NPV of gestalt was 98.4% (95%CI 98.0-98.8%) and 99.6% (95%CI 99.4-99.8%) for HEART Pathway (p<0.0001). Among 4052 patients with both gestalt and HEART Pathway assessments, the HEART Pathway correctly reclassified 9.1% (95% 8.3-10.0%) as low-risk. Prior to HEART Pathway implementation the sensitivity of gestalt was 78.8% (95%CI 72.3-84.1%), which improved to 95.9% (95%CI 91.9-98.0%) after HEART Pathway implementation (p<0.0001).
Conclusion: HEART Pathway is more sensitive for 30-day death and MI than gestalt and classifies more patients as low-risk. These findings suggest that HEART Pathway is a superior risk-stratification strategy. Our results also suggest that HEART Pathway implementation may train clinicians, enhancing their gestalt.