HEART Pathway: Combines the HEART Score with serial troponin monitoring to identify low-risk chest pain patients suitable for early discharge.
Guidelines & Evidence
Clinical Details
Section 1
When to Use
When to Use
Adult patients ≥ 21 years old presenting to the Emergency Department with chest pain or symptoms suspicious for Acute Coronary Syndrome (ACS).
To accelerate the identification of low-risk patients suitable for early discharge without further cardiac testing.
Do Not Use If
Patient has STEMI on ECG (activate Cath Lab), new ST-segment depression of ≥1mm, or hemodynamic instability. These patients are high-risk regardless of score.
Section 2
Formula & Logic
Pathway Logic
The HEART Pathway refines the original HEART score by adding a mandatory second troponin test (usually at 3 hours). A patient is categorized as "Low-Risk" only if their HEART Score is ≤ 3 AND both the initial (0h) and following (3h) troponin are negative.
The 1% Threshold
The primary goal is to safely rule out Major Adverse Cardiac Events (MACE), including MI, death, and urgent revascularization. The pathway is validated to identify patients with a < 1.0% risk of 30-day MACE.
Section 3
Pearls/Pitfalls
High-Sensitivity Troponin
Many modern institutions use high-sensitivity troponin assays (hsTn) with 0h/1h or 0h/2h algorithms. The HEART Pathway can be adapted to these rapid troponin protocols to achieve even faster disposition.
Impact of the Pathway
Implementation of the HEART Pathway has been shown to reduce objective cardiac testing (stress tests, CCTA) by ~12%, decrease the length of stay by ~10-12 hours, and reduce cost without increasing missed MACE events.
Section 4
Evidence Appraisal
Validation Studies
The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge.
Mahler SA et al. • Circ Cardiovasc Qual Outcomes.. 2015;8(2):195-203. The landmark randomized trial demonstrating safety and efficiency.
Chest pain in the emergency room: value of the HEART score.
Six AJ et al. • Neth Heart J.. 2008;16(6):191-6. The original derivation of the HEART score component.
