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New Protocol Helps Determine Discharge for Chest Pain Patients

WINSTON-SALEM, NC – One of the challenges when patients present to the emergency department with acute chest pain is determining which patients can be sent home safely and which need to be kept for more intensive care.

A risk-evaluation protocol, recently developed by the Wake Forest Baptist Medical Center, helps ED clinicians make that determination more efficiently, according to a report published recently in the journal Circulation: Cardiovascular Quality and Outcomes.

The study findsthat chest-pain patients evaluated with the new protocol, called the HEART Pathway, had 12% fewer cardiac tests, 21% more early discharges, and shorter hospital stays than those who received standard care. Yet, none of the patients identified for early discharge in either group had a major heart problem within 30 days of their ED visit.

Background information in the articles notes that as many as 10 million chest pain patients present for emergency care in the United States each year. More than half of those patients end up being hospitalized to undergo comprehensive cardiac tests at a national cost of between $10 billion and $13 billion annually.

Fewer than 10% of the patients are found to have acute coronary syndrome (ACS), however.

"The results of this trial demonstrate that, compared to usual care, the HEART Pathway can substantively decrease healthcare utilization among patients with symptoms related to ACS without compromising patient safety," said lead author Simon A. Mahler, MD, associate professor of emergency medicine at Wake Forest Baptist.

The HEART Pathway is based on the widely used HEART score system, which weighs five components –the patient's history, electrocardiogram reading, age, risk factors and levels of troponin, a protein in blood released when the heart muscle is damaged –to determine an individual's risk of having a serious cardiac problem. The Pathway also includes an additional element –a second blood test to measure troponin levels, administered three hours after the first one.

"The HEART Pathway is a decision aid, not a substitute for clinical judgment," Mahler said, "but there is strong evidence to support that its use can both improve evaluation and reduce unnecessary testing, hospitalization and expense."