Don’t Break Their Hearts - Discharging Patients with Moderate Risk HEART Scores from the Emergency Department
Abstract
Learning Objectives: To undertake an ED focused quality improvement initiative to allow for resident education in the fundamentals of research inquiry and study design and to provide experience in drafting research proposals, IRB submissions, medical abstracts and final manuscripts.
Background: Identifying patients at low risk for clinically relevant adverse cardiac events (CRACE) has the potential to decrease unnecessary hospitalizations. Earlier studies have shown that patients discharged with non-ischemic ECG and modified HEART (History, ECG, Age, Risk Factors, Troponin) score ≤3 had no deaths, acute myocardial infarctions (MI), or coronary revascularization events at 30 days. New observational data suggest the rate of CRACE for patients classified as moderate-risk by HEART score of 4-6 may be similarly low.
Objective: To determine the incidence of CRACE in patients discharged with a moderate-risk HEART score.
Methods: We reviewed ED visits involving adults presenting to an urban teaching hospital in Washington, DC. A prior quality improvement project determined the low overall rate of CRACE in patients with 2 negative 4th generation troponins, allowing clinicians to discharge patients with a HEART score of 4-6. This study was an analysis of patients with inclusion criteria of: (1) primary diagnosis code of chest pain for either ED reason for visit or discharge, (2) HEART score of 4-6, and (3) discharge from December 1, 2019 to March 15th, 2020.
Outcomes: The primary outcome was the 30 day rate of CRACE, defined as all-cause mortality, STEMI, fatal arrhythmia, and cardiopulmonary arrest. Secondary outcome was the rate of NSTEMI within 30 days of ED visit.
Results: 298 patients with HEART score 4-6 were discharged. 296 of 298 patients were alive with no recorded events at 30 days. Two patients had no available follow up data. Overall, the CRACE rate was 0% and NSTEMI rate was 0.34% within 30 days of discharge. One discharged patient followed up with cardiology and prior to arranged stress testing, re-presented with worsening chest pain and was found to have NSTEMI.
Conclusion: CRACE and NSTEMI are exceedingly rare within 30 days of ED discharge for patients with a moderate risk HEART score.