Abstract:

Background and Objectives: Over half of adults presenting to the emergency department (ED) with acute chest pain are admitted to the hospital for suspected acute coronary syndrome (ACS), though fewer than 10% are ultimately diagnosed with this disease. The HEART Pathway and coronary CT angiography are two risk stratifying tools that have separately demonstrated high negative predictive value in ruling out ACS in lower risk groups. Yet, no studies have tested whether integration of these tools could further reduce hospital admissions. We developed a Smart Form embedded in the electronic health record (EHR) that combines these tools – called HEART-CT – and provides management recommendations. The aims of this study are to test the safety of HEART-CT and compare clinical outcomes in HEART-CT adherent vs nonadherent groups.

Methods: This was a cohort study in a tertiary academic center. Patients ≥ 21 years old with a chief complaint of chest pain, a troponin result, and a completed HEART-CT Smart Form in the EHR were included. Patients with ED diagnosed ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) were excluded. Researchers blinded to adherence assessed outcomes by chart review. Outcomes included MACE within 30 days, ED disposition, ED length of stay (LOS), and provider adherence to HEART-CT. Categorical and numeric variables were compared using chi-squared and independent t-tests, respectively. Odds ratios were calculated by logistic regression.

Results: Of the 688 patients that met inclusion criteria, 16 were excluded for ED diagnosed STEMI or NSTEMI. Thus, 672 patients were included. 78.1% (525/672) were ED discharged. No patients identified as low risk (0/437) had MACE within 30 days (sensitivity 100%, p < 0.001). In patients with increased risk scores, ED discharge was 3.41 times more likely when providers were HEART-CT adherent than nonadherent (95% CI 2.20-5.27). There were no differences detected in MACE rates (OR 2.01, 95% CI 0.92-4.37) or ED LOS (-0.43 hours, 95% CI -0.92 to 0.83) when providers were adherent vs nonadherent, respectively.

Conclusion: HEART-CT identified 78.1% of chest pain patients as safe for discharge and demonstrated 100% sensitivity for 30-day MACE. Adherence to HEART-CT in patients with high risk scores resulted in increased ED discharge rates without increasing MACE or LOS compared to nonadherence.