The HEART Pathway Randomized Controlled Trial One-year Outcomes

2023 Society for Academic Emergency Medicine Consensus Conference on Precision Emergency Medicine: Development of a policy-relevant, patient-centered research agenda

OBJECTIVES

Precision medicine is data-driven health care tailored to individual patients based on their unique attributes, including biologic profiles, disease expressions, local environments, and socioeconomic conditions. Emergency medicine (EM) has been peripheral to the precision medicine discourse, lacking both a unified definition of precision medicine and a clear research agenda. We convened a national consensus conference to build a shared mental model and develop a research agenda for precision EM.

METHODS

We held a conference to (1) define precision EM, (2) develop an evidence-based research agenda, and (3) identify educational gaps for current and future EM clinicians. Nine preconference workgroups (biomedical ethics, data science, health professions education, health care delivery and access, informatics, omics, population health, sex and gender, and technology and digital tools), comprising 84 individuals, garnered expert opinion, reviewed relevant literature, engaged with patients, and developed key research questions. During the conference, each workgroup shared how they defined precision EM within their domain, presented relevant conceptual frameworks, and engaged a broad set of stakeholders to refine precision EM research questions using a multistage consensus-building process.

RESULTS

A total of 217 individuals participated in this initiative, of whom 115 were conference-day attendees. Consensus-building activities yielded a definition of precision EM and key research questions that comprised a new 10-year precision EM research agenda. The consensus process revealed three themes: (1) preeminence of data, (2) interconnectedness of research questions across domains, and (3) promises and pitfalls of advances in health technology and data science/artificial intelligence. The Health Professions Education Workgroup identified educational gaps in precision EM and discussed a training roadmap for the specialty.

CONCLUSIONS

A research agenda for precision EM, developed with extensive stakeholder input, recognizes the potential and challenges of precision EM. Comprehensive clinician training in this field is essential to advance EM in this domain.

Rural and socioeconomic differences in the effectiveness of the HEART Pathway accelerated diagnostic protocol

BACKGROUND

The HEART Pathway is a validated accelerated diagnostic protocol (ADP) for patients with possible acute coronary syndrome (ACS). This study aimed to compare the safety and effectiveness of the HEART Pathway based on patient rurality (rural vs. urban) or socioeconomic status (SES).

METHODS

We performed a preplanned subgroup analysis of the HEART Pathway Implementation Study. The primary outcomes were death or myocardial infarction (MI) and hospitalization at 30 days. Proportions were compared by SES and rurality with Fisher's exact tests. Logistic regression evaluated for interactions of ADP implementation with SES or rurality and changes in outcomes within subgroups.

RESULTS

Among 7245 patients with rurality and SES data, 39.9% (2887/7245) were rural and 22.2% were low SES (1607/7245). The HEART Pathway identified patients as low risk in 32.2% (818/2540) of urban versus 28.1% (425/1512) of rural patients (p = 0.007) and 34.0% (311/915) of low SES versus 29.7% (932/3137) high SES patients (p = 0.02). Among low-risk patients, 30-day death or MI occurred in 0.6% (5/818) of urban versus 0.2% (1/425) rural (p = 0.67) and 0.6% (2/311) with low SES versus 0.4% (4/932) high SES (p = 0.64). Following implementation, 30-day hospitalization was reduced by 7.7% in urban patients (adjusted odds ratio [aOR] 0.76, 95% confidence interval [CI] 0.66-0.87), 10.6% in low SES patients (aOR 0.68, 95% CI 0.54-0.86), and 4.5% in high SES patients (aOR 0.83, 95% CI 0.73-0.94). However, rural patients had a nonsignificant 3.3% reduction in hospitalizations.

CONCLUSIONS

HEART Pathway implementation decreased 30-day hospitalizations regardless of SES and for urban patients but not rural patients. The 30-day death or MI rate was similar among low-risk patients.

Age differences in the safety and effectiveness of the HEART Pathway accelerated diagnostic protocol for acute chest pain

BACKGROUND

The HEART Pathway is a validated protocol for risk stratifying emergency department (ED) patients with possible acute coronary syndrome (ACS). Its performance in different age groups is unknown. The objective of this study is to evaluate its safety and effectiveness among older adults.

METHODS

A pre-planned subgroup analysis of the HEART Pathway implementation study was conducted. This prospective interrupted time series accrued adult ED patients with possible ACS who were without ST-elevation across three US sites from 11/2013-01/2016. After implementation, providers prospectively used the HEART Pathway to stratify patients as low-risk or non-low-risk. Patients were classified as older adults (≥65 years), middle-aged (46-64 years), and young (21-45 years). Primary safety and effectiveness outcomes were 30-day death or MI and hospitalization at 30 days, determined from health records, insurance claims, and death index data. Fisher's exact test compared low-risk proportions between groups. Sensitivity for 30-day death or MI and adjusted odds ratios (aORs) for hospitalization and objective cardiac testing were calculated.

RESULTS

The HEART Pathway implementation study accrued 8474 patients, of which 26.9% (2281/8474) were older adults, 45.5% (3862/8474) middle-aged, and 27.5% (2331/8474) were young. The HEART Pathway identified 7.4% (97/1303) of older adults, 32.0% (683/2131) of middle-aged, and 51.4% (681/1326) of young patients as low-risk (p < 0.001). The HEART Pathway was 98.8% (95% CI 97.1-100) sensitive for 30-day death or MI among older adults. Following implementation, the rate of 30-day hospitalization was similar among older adults (aOR 1.25, 95% CI 1.00-1.55) and cardiac testing increased (aOR 1.25, 95% CI 1.04-1.51).

CONCLUSION

The HEART Pathway identified fewer older adults as low-risk and did not decrease hospitalizations in this age group.

Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter?

BACKGROUND

Despite negative troponins and nonischemic electrocardiograms (ECGs), patients at moderate risk for acute coronary syndrome (ACS) are frequently admitted. The objective of this study was to describe the major adverse cardiac event (MACE) rate in moderate-risk patients and how it differs based on history of coronary artery disease (CAD).

METHODS

A secondary analysis of the HEART Pathway implementation study was conducted. This prospective interrupted time-series study accrued adults with possible ACS from three sites (November 2013-January 2016). This analysis excluded low-risk patients determined by emergency providers' HEART Pathway assessments. Non-low-risk patients were further classified as high risk, based on elevated troponin measures or ischemic ECG findings or as moderate risk, based on HEAR score ≥ 4, negative troponin measures, and a nonischemic ECG. Moderate-risk patients were then stratified by the presence or absence of prior CAD (MI, revascularization, or ≥70% coronary stenosis). MACE (death, myocardial infarction, or revascularization) at 30 days was determined from health records, insurance claims, and death index data. MACE rates were compared among groups using a chi-square test and likelihood ratios (LRs) were calculated.

RESULTS

Among 4,550 patients with HEART Pathway assessments, 24.8% (1,130/4,550) were high risk and 37.7% (1715/4550) were moderate risk. MACE at 30 days occurred in 3.1% (53/1,715; 95% confidence interval [CI] = 2.3% to 4.0%) of moderate-risk patients. Among moderate-risk patients, MACE occurred in 7.1% (36/508, 95% CI = 5.1% to 9.8%) of patients with known CAD versus 1.4% (17/1,207, 95% CI = 0.9% to 2.3%) in patients without known prior CAD (p < 0.0001). The negative LR for 30-day MACE among moderate-risk patients without prior CAD was 0.08 (95% CI = 0.05 to 0.12).

CONCLUSION

MACE rates at 30 days were low among moderate-risk patients but were significantly higher among those with prior CAD.

External validation of a low HEAR score to identify emergency department chest pain patients at very low risk of major adverse cardiac events without troponin testing

BACKGROUND

The history, ECG, age, risk factor (HEAR) score has been proposed to identify patients at sufficiently low risk of acute coronary syndrome that they may not require troponin testing. The objective of this study was to externally validate a low HEAR score to identify emergency department (ED) patients with chest pain at very low risk of 30-day major adverse cardiac events (MACE).

METHODS

This was a secondary analysis of a prospective cohort of patients requiring troponin testing to rule out myocardial infarction (MI) in a large urban ED. HEAR scores were calculated in two cohorts: (1) patients with no known history of coronary artery disease (CAD); and (2) all eligible patients. The proportion of patients classified as very low risk, sensitivity, specificity, predictive values and likelihood ratios at each cut-off were quantified for index acute myocardial infarction (AMI) and 30-day MACE at HEAR = 0 and HEAR ≤ 1 thresholds.

RESULTS

Of the 1150 patients included in this study, 820 (71.3%) had no history of CAD, 97 (8.4%) had index AMI and 123 (10.7%) had 30-day MACE. In patients with no prior history of CAD, HEAR ≤ 1 identified 202 (24.6%) of patients as very low risk for 30-day MACE with 98.4% (95% CI 91.6-99.9%) sensitivity. Among all patients, HEAR ≤ 1 identified 202 (17.6%) patients as very low risk for 30-day MACE with 99.2% (95% CI 95.6-99.9%) sensitivity.

CONCLUSIONS

A HEAR score ≤ 1 can identify more than 17% of all patients as very low risk for index AMI and 30-day MACE and unlikely to benefit from troponin testing. Broad implementation of this strategy could lead to significant resource savings.

Validation and modification of HEART score components for patients with chest pain in the emergency department

OBJECTIVE

This study aimed to clarify the relative prognostic value of each History, Electrocardiography, Age, Risk Factors, and Troponin (HEART) score component for major adverse cardiac events (MACE) within 3 months and validate the modified HEART (mHEART) score.

METHODS

This study evaluated the HEART score components for patients with chest symptoms visiting the emergency department from November 19, 2018 to November 19, 2019. All components were evaluated using logistic regression analysis and the scores for HEART, mHEART, and Thrombolysis in Myocardial Infarction (TIMI) were determined using the receiver operating characteristics curve.

RESULTS

The patients were divided into a derivation (809 patients) and a validation group (298 patients). In multivariate analysis, age did not show statistical significance in the detection of MACE within 3 months and the mHEART score was calculated after omitting the age component. The areas under the receiver operating characteristics curves for HEART, mHEART and TIMI scores in the prediction of MACE within 3 months were 0.88, 0.91, and 0.83, respectively, in the derivation group; and 0.88, 0.91, and 0.81, respectively, in the validation group. When the cutoff value for each scoring system was determined for the maintenance of a negative predictive value for a MACE rate >99%, the mHEART score showed the highest sensitivity, specificity, positive predictive value, and negative predictive value (97.4%, 54.2%, 23.7%, and 99.3%, respectively).

CONCLUSION

Our study showed that the mHEART score better detects short-term MACE in high-risk patients and ensures the safe disposition of low-risk patients than the HEART and TIMI scores.

Scoring systems for the triage and assessment of short-term cardiovascular risk in patients with acute chest pain

Acute chest pain is a common emergency department (ED) chief complaint. Evaluating patients for acute coronary syndrome is challenging because missing the diagnosis carries substantial morbidity, mortality, and medicolegal consequences. However, over-testing is associated with increased cost, overcrowding, and possible iatrogenic harm. Over the past two decades, multiple risk scoring systems have been developed to help emergency providers evaluate patients with acute chest pain. The ideal risk score balances safety by achieving high sensitivity and negative predictive value for major adverse cardiovascular events while also being effective in identifying a large proportion of patients for early discharge from the ED. This review examines contemporary risk scores used to risk stratify patients with acute chest pain.

Not all HEART scores are created equal: identifying "low-risk" patients at higher risk

OBJECTIVE

We sought to identify sub-groups of "low-risk" HEART score patients (history, ECG, age, risk factors, and troponin) at elevated risk of acute myocardial infarction or death within 30 days.

METHODS

We performed a secondary analysis of prospective emergency department (ED) encounters for suspected acute coronary syndrome in a large health system with low-risk HEART scores (0-5 points). Logistic regression using the 5 components of the HEART score analyzed the increase risk attributable to points from each of the 5 score components.

RESULTS

Of 30,971 encounters among 28,992 unique patients, 135 (0.44%, 95% confidence interval [CI] = 0.37-0.51) experienced acute myocardial infarction or death. Risk increased for each component of the HEART score from 0 to 1 to 2 points (history, 0.4% to 0.5% to 0.6%; ECG, 0.3% to 0.7% to 0.7%; age, 0.2% to 0.3% to 0.7%; risk factors, 0.1% to 0.4% to 0.8%), except troponin, which had the highest risk with 1 point (troponin, 0.4% to 2.7% to 0.9%). Odds ratios from our regression, which adjusts for other components, showed a similar pattern (from 1 vs 0 and 2 vs 0 points, respectively: history, 1.0 and 1.8; ECG, 2.2 and 3.5; age, 1.2 and 2.1; risk factors, 2.4 and 4.2; and troponin, 6.0 and 3.6).

CONCLUSION

Among "low-risk" suspected acute coronary syndrome encounters, increasing points within each of the 5 categories demonstrated small increases in risk of death or acute myocardial infarction, with the troponin and ECG components representing the largest risk increases.

Real-time AI prediction for major adverse cardiac events in emergency department patients with chest pain

Background

A big-data-driven and artificial intelligence (AI) with machine learning (ML) approach has never been integrated with the hospital information system (HIS) for predicting major adverse cardiac events (MACE) in patients with chest pain in the emergency department (ED). Therefore, we conducted the present study to clarify it.

Methods

In total, 85,254 ED patients with chest pain in three hospitals between 2009 and 2018 were identified. We randomized the patients into a 70%/30% split for ML model training and testing. We used 14 clinical variables from their electronic health records to construct a random forest model with the synthetic minority oversampling technique preprocessing algorithm to predict acute myocardial infarction (AMI) < 1 month and all-cause mortality < 1 month. Comparisons of the predictive accuracies among random forest, logistic regression, support-vector clustering (SVC), and K-nearest neighbor (KNN) models were also performed.

Results

Predicting MACE using the random forest model produced areas under the curves (AUC) of 0.915 for AMI < 1 month and 0.999 for all-cause mortality < 1 month. The random forest model had better predictive accuracy than logistic regression, SVC, and KNN. We further integrated the AI prediction model with the HIS to assist physicians with decision-making in real time. Validation of the AI prediction model by new patients showed AUCs of 0.907 for AMI < 1 month and 0.888 for all-cause mortality < 1 month.

Conclusions

An AI real-time prediction model is a promising method for assisting physicians in predicting MACE in ED patients with chest pain. Further studies to evaluate the impact on clinical practice are warranted.

HEART Pathway Implementation Safely Reduces Hospitalizations at One Year in Patients With Acute Chest Pain

STUDY OBJECTIVE

We determine whether implementation of the HEART (History, ECG, Age, Risk Factors, Troponin) Pathway is safe and effective in emergency department (ED) patients with possible acute coronary syndrome through 1 year of follow-up.

METHODS

A preplanned analysis of 1-year follow-up data from a prospective pre-post study of 8,474 adult ED patients with possible acute coronary syndrome from 3 US sites was conducted. Patients included were aged 21 years or older, evaluated for possible acute coronary syndrome, and without ST-segment elevation myocardial infarction. Accrual occurred for 12 months before and after HEART Pathway implementation, from November 2013 to January 2016. The HEART Pathway was integrated into the electronic health record at each site as an interactive clinical decision support tool. After integration, ED providers prospectively used the HEART Pathway to identify patients with possible acute coronary syndrome as low risk (appropriate for early discharge without stress testing or angiography) or nonlow risk (appropriate for further inhospital evaluation). Safety (all-cause death and myocardial infarction) and effectiveness (hospitalization) at 1 year were determined from health records, insurance claims, and death index data.

RESULTS

Preimplementation and postimplementation cohorts included 3,713 and 4,761 patients, respectively. The HEART Pathway identified 30.7% of patients as low risk; 97.5% of them were free of death and myocardial infarction within 1 year. Hospitalization at 1 year was reduced by 7.0% in the postimplementation versus preimplementation cohort (62.1% versus 69.1%; adjusted odds ratio 0.70; 95% confidence interval 0.63 to 0.78). Rates of death or myocardial infarction at 1 year were similar (11.6% versus 12.4%; adjusted odds ratio 1.00; 95% confidence interval 0.87 to 1.16).

CONCLUSION

HEART Pathway implementation was associated with decreased hospitalizations and low adverse event rates among low-risk patients at 1-year follow-up.