The Journal of Emergency Medicine, Vol. -, No. -, pp.

1–7, 2020
Ó 2020 Elsevier Inc. All rights reserved.
0736-4679/$ - see front matter

https://doi.org/10.1016/j.jemermed.2020.12.004

Original
Contributions

UTILITY OF HEART PATHWAY IN IDENTIFYING LOW-RISK CHEST PAIN IN

EMERGENCY DEPARTMENT

Dipanjan Halder, MD,* Roshan Mathew, MD,* Nayer Jamshed, MD,* Sakshi Yadav, MD,* Brunda RL, MD,*
Praveen Aggarwal, MD,* and Rajiv Narang, DM†
*Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India and †Department of Cardiology, All India Institute
of Medical Sciences, New Delhi, India
Reprint Address: Roshan Mathew, MD, Department of Emergency Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
110029, India

, Abstract—Background: Chest pain is a common pre-
senting symptom in the emergency department (ED).
The HEART (history, electroencephalogram [ECG],
age, risk factors, and troponin I) score, with addition
of troponin at 3 h, helps to determine appropriate risk
stratification of the patients. Objective: This study evalu-
ated the utility of the HEART pathway as a decision aid
designed for risk stratification of patients with acute-
onset chest pain for early and safe disposition. Methods:
This was a prospective observational study done in a ter-
tiary care center. Focused history, 12-lead ECG, and base-
line troponin I level on arrival and at hour 3 were
recorded. Subjects were classified as low risk (HEART
score 0–3) or high risk (HEART score $ 4). Patients
with a HEART score of 0–3 with negative troponin I at
3 h were discharged and were followed up for major
adverse cardiac events (MACEs) within 30 days of ED
presentation. Results: A total of 250 patients were
screened for the study, of which 151 were included for
the final analysis. One hundred and two patients (68%)
were male and 54% of patients were younger than
45 years. HEART scores of 0 (n = 16), 1 (n = 43), 2
(n = 44), and 3 (n = 48) were observed. There was only 1
MACE (0.7%) in 30 days after ED discharge in the study
population. The mean length of ED stay in the low-risk
group was 4.5 h. Conclusions: Low-risk patients, as per
the HEART pathway, can be discharged safely from the
ED, which reduces ED stay and health care resource
use. Ó 2020 Elsevier Inc. All rights reserved.
, Keywords—chest pain; acute coronary syndrome; ma-
jor adverse cardiac event; emergency
INTRODUCTION
Chest pain is a common symptom, which constitutes
approximately 10% of all emergency department (ED)
visits (1–3). Acute coronary syndrome (ACS) is a life-
threatening condition that requires prompt diagnosis
and treatment (4). In a busy ED, ACS must be differenti-
ated from other non–life-threatening causes of chest pain.
This differentiation is often difficult, time-consuming,
costly, and resource-intensive (5). That is why an objec-
tive method is required to risk-stratify patients quickly
(6). Goldman et al. proposed a computer-based protocol
in 1988 to predict myocardial infarction (MI) and reduce
admissions to cardiac care units by 11.5% (7). Among
several scoring systems, the HEART (history, electrocar-
diogram [ECG], age, risk factors, and troponin I) score is
a very convenient scoring system that requires less-
extensive workup and calculation (8,9). Adding to the
HEART score, a troponin level at 3 h, called the HEART
pathway, helps improve risk stratification and minimizes
delay in decision making (10–12).

RECEIVED: 17 September 2020; FINAL SUBMISSION RECEIVED: 22 November 2020;

ACCEPTED: 6 December 2020

1
2 D. Halder et al.

METHODS Patients who got discharged from the ED were fol-

lowed up for major adverse cardiac events (MACEs).
We conducted a prospective observational study in the MACEs included STEMI, non-STEMI (NSTEMI), emer-
ED of a tertiary care hospital in New Delhi, India. After gency revascularization, cardiovascular death due to
ethical clearance from the Institute Ethics Committee dysrhythmia, cardiac arrest, cardiogenic shock, high-
(IECPG-233/23.08.2017, RT-24/28.09.2017), data were degree atrioventricular block, and death due to any cause
collected prospectively from November 2017 to April within 30 days of hospital presentation. They were also
2019. Patients who came with acute-onset chest pain asked whether some objective cardiac testing, such as ex-
were asked for a detailed history about the character of ercise treadmill testing, stress radionuclide myocardial
the chest pain and risk factors for coronary artery disease perfusion imaging, stress echocardiography, cardiac
(CAD). It was followed by a 12-lead ECG and troponin I magnetic resonance imaging, computed tomographic
level at 0 h. Patients with ST-elevation myocardial infarc- coronary angiogram, or invasive coronary angiography
tion (STEMI) on ECG and who were hemodynamically was done within this time period. Their duration of ED
unstable were excluded from the study. A nonspecific his- stay was also noted.
tory that was not consistent with chest pain concerning For statistical analysis, a sample size of 150 was deter-
for ACS was considered slightly suspicious. A mixed his- mined as adequate, assuming a confidence level of 95%,
torical element—a history that contains traditional and 80% power, and anticipating the percentage of low -risk
nontraditional elements of typical ACS presentation— patients as 30% of total chest pain patients and risk of
was considered moderately suspicious. A specific history MACE as 3%. Data were recorded on a predesigned pro-
for ACS, with traditional features of ACS, was considered forma and managed on an Excel (Microsoft) spreadsheet.
highly suspicious. Specific risk factors for CAD were Categorical variables were summarized by frequency
determined and based on the ECG findings and troponin (%). All statistical analysis was carried out by using
levels; HEART score was calculated at 0 h. SPSS statistical software (IBM Corp). Descriptive statis-
HEART score is a convenient tool for risk-stratifying tics of the baseline characteristics were presented as
chest pain patients in the ED. It is a bedside scoring sys- mean 6 standard deviation (SD).
tem that can be calculated easily by any trained ED nurse,
emergency physician, or cardiologist (13). HEART is an RESULTS
acronym for history of the patient regarding chest pain,
ECG characteristics, age of the patient, risk factors for A total of 250 patients with chest pain were screened for
cardiovascular disease, and troponin I level at presenta- eligibility, of which 88 were excluded from the study
tion. Each component is scored from 0 to 2, according because their HEART score was > 3, troponin was not
to the patient’s history and investigatory findings. Total done at 0 h or patient did not give the consent for the
scoring stratifies the patients with chest pain into the study. Eleven patients were lost to follow-up, so they
following categories, low risk (score 0–3), moderate were also excluded (Figure 2).
risk (score 4–6), and high risk (score 7–10) (8,9).
For this study, patients with a HEART score of $ 4 Table 1. HEART Score Components for Patients with
Acute-Onset Chest Pain
were stratified into the high-risk group and those with a
HEART score of 0–3 were stratified into the low-risk Component Variable Score
group (Table 1). Patients in the high-risk group were
History Highly suspicious 2
also excluded from the study. At 3 h, a repeat troponin I Moderately suspicious 1
level was determined, as for the HEART pathway Slightly suspicious 0
(Figure 1). ECG Significant ST depression 2
Nonspecific repolarization disturbances 1
HEART pathway is a decision-making aid that incor- Normal 0
porates HEART score and serial troponin assay in pa- Age $65 years 2
tients with chest pain regarding early discharge or 45–64 years 1
#44 years 0
prolonged ED observation or admission under cardiology Risk factors $3 risk factors are present or history of 2
department for investigations (e.g., stress testing and car- atherosclerotic disease
diac magnetic resonance imaging). High-risk (score $ 4) 1–2 risk factors 1
No risk factors 0
patients are generally admitted for interventions or kept Troponin $3 of normal limit 2
under observation and low-risk patients (score 0–3) are 1–3 of normal limit 1
either discharged early or kept under observation if the Below or at normal limit 0
presentation is suspicious or if serial troponin value (3- ECG = electrocardiogram; HEART = history, electrocardiogram,
h troponin I) is in a rising trend (10–12,14). age, risk factors, and troponin I.
Utility of HEART Pathway for Chest Pain in the ED
Figure 1. HEART (history, electrocardiogram, age, risk factors, and troponin I) pathway.
Of 151 patients, most were male (n = 102 [68%]).
Fifty-four percent of the patients were younger than
45 years. Mean 6 SD age of the study population was
43.3 6 11.67 years. Time taken for ED presentation after
the onset of chest pain ranged from 30 min to 12 h. Pa-
tients most commonly presented with heaviness of chest,
with left side of the chest being the most common site. In
approximately 67.5% patients, there was no radiation of
chest pain. Diaphoresis was the most common associated
symptoms (31.1%). Aggravating or relieving factors,
such as chest pain aggravated in deep inspiration, after
strenuous work, on palpation, and relieved by taking
rest or sublingual nitrate, were present in only 5.3% of
cases (Table 2).
Calculation of HEART Score
History was moderately suspicious in most patients (54%),
and ECG changes were absent in 84.1%. Only 24 patients
(16%) had ECG changes such as repolarization abnormal-
3
ities without significant ST segment depression, bundle
branch block, typical abnormalities indicative of left ven-
tricular hypertrophy, and repolarization abnormalities
probably due to the use of digoxin or unknown repolariza-
tion disturbances. Eighty-two patients were younger than
45 years and 65 patients were between the ages of 45
and 64 years. Among risk factors, hypertension was the
most common (24%) risk factor in the study population,
followed by smoking (16.5%) and diabetes (14.5%).
Most patients (53.6%) had at least one to two risk factors.
Only 4 patients among the low-risk group patients had
three or more risk factors. Most of the patients in the
low-risk group (n = 147 [97.4%]) had a 0-h troponin I level
that was below the upper normal limit.
Among the study population, 43 patients (28.5%) had
a HEART score of 1 and 44 (29.1%) and 48 patients
(31.8%) had HEART scores of 2 and 3, respectively
(Table 3).
Of 151 low-risk patients who were discharged early
without cardiac imaging or stress test and were followed
4 D. Halder et al.

Table 2. Baseline Characteristics of Discrete Variables

(n = 151)

Variable n %

Sex
Male 102 67.55
Female 49 32.45
Age
<45 years 82 54
45–64 years 65 43
>65 years 4 3
Site of chest pain
Central 64 42.38
Left 82 54.30
Right 5 3.31
Characteristics of chest pain
Heaviness 95 62.91
Pricking 27 17.88
Throbbing 15 9.93
Burning 14 9.27
Radiation towards
No radiation 102 67.55
Left arm 36 23.84
Right arm 6 3.97
Figure 2. Flow chart showing recruitment of patients in Both arm 1 0.66
study. Back 6 3.97
Associated symptoms
Diaphoresis 47 31.13
up for 30 days after ED presentation, only 1 had an Nausea 25 16.56
MACE (0.6%) as NSTEMI. His HEART score on ED pre- Vomiting 13 8.61
Palpitation 26 17.22
sentation was 3 (age score 2, risk factor score 1 for smok- Dizziness 4 2.65
ing). Aggravating or relieving factors 8 5.30
Mean length of hospital stay for low-risk patients Risk factors
Diabetes 22 14.57
(n = 151) was 4.5 h. Hypertension 37 24.50
Hypercholesterolemia 8 5.33
Smoking 25 16.56
DISCUSSION History of CAD 11 7.28
Family history of CVD 7 4.64
Chest pain is one of the frequently encountered presenta- Obesity 15 9.93
tions in the ED (4).The most common life-threatening CAD = coronary artery disease; CVD = cardiovascular death.
differential for chest pain is ACS (15). The complete eval-
uation to rule out ACS is resource-intensive and results in
longer ED stays. In a busy ED, it is very difficult to make older than 65 years could be included, as most of the
a decision to either intensively investigate or discharge elderly population had a HEART score of > 3. Most pa-
the patient with an advise for outpatient department tients included in our study were younger than 45 years.
(OPD) follow-up (16). In their study, Schull et al. found Contrary to the Western population, cardiovascular death
that the rate of missed acute MI ranged from 0 to 29% (CVD) affects Indians 1 decade sooner and the case fatal-
across EDs (17). A miss rate of < 1% for MACE is ity rate is also high in low-income groups (23–25). In
deemed acceptable for a screening tool (18). Various Southeast Asia, one-half of the CVDs occur before the
risk-stratification scores have been developed to aid age of 50 years, and 25% of MIs occur in those younger
emergency physicians (EPs) with decision making, of than 40 years (26). Proper risk stratification of the young
which the HEART score outperforms most (19–21). population presenting with chest pain is extremely impor-
The HEART pathway (which adds serial troponin tant.
measurements at 0 and 3 h to the HEART score) has a The most common risk factor among the study popu-
higher sensitivity and negative predictive value for lation was hypertension (24.5%), followed by smoking
adverse cardiac events than the HEART score alone (16.6%). The INTERHEART study, involving 52 coun-
(22). Our study also revealed that use of the HEART tries, established an association between conventional
pathway helped the EP discharge low-risk patients safely, modifiable risk factors for MI in the world, including
with an MACE incidence of 0.7% at 30 days. both sexes and all ages (27). They found hypertension,
A broad age group ranging from 18 to 81 years was obesity, and diabetes had more severe effects in South
screened for eligibility in our study, but only 4 patients Asia. This study also found that hypertension and
Utility of HEART Pathway for Chest Pain in the ED 5

Table 3. HEART Score Components pathway (33). There are several studies available
regarding the HEART score and HEART pathway among
Variable n %
European and American population showing a minimal
History (score) risk of MACE in a low-risk group of patients presenting
Not suspicious (0) 68 45 with acute-onset chest pain (10,11).
Moderately suspicious (1) 81 54
Highly suspicious (2) 2 1 In our study population, the total low-risk group pa-
ECG changes (score) tients (n = 151) who were discharged early had a 30-
Normal (0) 127 84.1 day MACE rate of 0.7%, and only 1 patient had NSTEMI
Repolarization abnormalities without 24 15.9
significant ST segment depression (1) after 30 days of ED presentation. In previous studies done
Age (score) by Six et al., Backus et al., Mahler et al., Melki et al., Na-
<45 years (0) 82 54 tarajan et al., Sun et al., and Frisoli et al., the risk of
45–64 years (1) 65 43
>65 years (2) 4 3 MACE ranged from 0% to 2.6% (3,8–10,12,21,22,34–
No. of risk factors (score) 36). Our study result is also consistent with their results.
Zero (0) 66 43.71 Patients in low-risk groups were discharged after res-
One (1) 50 33.11
Two (1) 31 20.53 olution of their symptoms and asked to follow-up in
Three (2) 4 35.76 OPDs. Although the HEART scoring is done at 0 h and
Troponin I at 0 h (score) decision-making is done on the basis of hour 3 troponin
WNL (0) 147 97.4
<3 UNL (1) 4 2.6 value in the HEART pathway, our low-risk patients had
HEART score a mean door-to-discharge time of 4.5 h. In a study by Fri-
0 16 10.6 soli et al., hospital length of stay (LOS) was approxi-
1 43 28.48
2 44 29.14 mately 6.3 h for low-risk patients (12). The discharge
3 48 31.79 time after the hour-3 troponin value was affected in
many ways due to persistent symptoms, delay in collec-
ECG = electrocardiogram; HEART = history, electrocardiogram,
age, risk factors, and troponin I; UNL = upper normal limit; tion of reports, and other logistic issues.
WNL = within normal limit. Five patients had undergone cardiac imaging or stress
testing within 30 days of ED presentation due to recurrent
symptoms. Two of them underwent treadmill testing or
diabetes were more important risk factors in younger In- stress testing and 3 underwent coronary angiography.
dian women than men. Test results were normal for all 5 patients who underwent
Similar to our study, several comparative studies of cardiac stress testing or imaging.
different scoring systems for chest pain by Poldervaart Patients who had chest pain were treated initially with
et al., Sakamoto et al., Nieuwets et al., de Hoog et pain medications, such as paracetamol (NSAIDs), trama-
al. found that HEART score was instrumental in identi- dol, or morphine according to pain severity. Those with a
fying low-risk patients and having minimum cardiac highly suspicious history with risk factors and ECG with
adverse events in the future (19,20,28,29). A study by ST-T changes were given a loading dose with dual anti-
de Hoog et al. reported that HEART score performance platelets and statins. Most of the patients with chest
in predicting MACE in the low-risk group was similar pain were suspected of having gastrointestinal etiology
in different ethnicities (29). This study was done among (gastroesophageal reflux disease or peptic ulcer disease)
the Indian population, where a total of 151 low-risk pa- or muscular pain and were treated accordingly. In a few
tients (HEART score 0–3), according to the HEART patients, cause of chest pain could not be determined,
pathway, were discharged early without additional car- test results were negative, and they were discharged per
diac imaging and stress test from emergency and were HEART pathway protocol. During follow-up, 2 patients
followed up to 30 days post presentation to ED for developed pneumonia 3–4 days after ED presentation,
MACE. and they were admitted to another hospital and recovered
Kline et al. calculated that a < 2% missed ACS rate is completely.
acceptable and that at this threshold the risk of additional
testing outweighs the benefit of confirming ACS (30). Limitations
The HEART pathway, which includes HEART score
and serial troponin assay, is a convenient tool for risk This was a single-center study with a small sample size.
stratification with good inter-operator reliability (31). It Few patients were excluded because of reasons such as
also prevents unnecessary admissions and reduces the loss to follow-up, delay in first medical contact after tri-
cost burden on patients and the hospital (32). A study aging, and nonadherence to study protocol. Disposition
by Hyams et al. found an absolute reduction of 15.3% was delayed in a few cases due to overcrowding in the
in admission rates post application of the HEART ED. A study comparing single troponin value with serial
6 D. Halder et al.
troponin values (0 and 3 h) in these low-risk subsets
would help us determine whether the second troponin
can be avoided and further reduce ED stay.
CONCLUSIONS
HEART pathway is an excellent tool for risk stratification
of ACS in ED. It is extremely effective for predicting
MACE at 30 days and can therefore obviate objective car-
diac testing in low-risk patients. It is also useful for early
and safe disposition from a busy ED without compro-
mising patient safety.
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Utility of HEART Pathway for Chest Pain in the ED 7

ARTICLE SUMMARY
1. Why is this topic important?
Chest pain is a frequent emergency department (ED)
presentation. Proper risk stratification of the patient helps
in early discharge and reduces ED overcrowding.
2. What does this study attempt to show?
The study demonstrates the use of HEART (history,
electrocardiogram, age, risk factors, and troponin I)
pathway in identifying patients with low-risk chest pain.
3. What are the key findings?
In patients categorized as low-risk on HEART pathway,
the incidence of major adverse cardiac events was 0.6%.
4. How is patient care impacted?
The HEART pathway is a good tool for emergency phy-
sicians to appropriately risk-stratify patients with chest
pain, allowing early discharge and preventing ED over-
crowding.