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

Nicklaus P Ashburn, Anna C Snavely, Brennan E Paradee, James C O'Neill, Jason P Stopyra, Simon A Mahler, Nicklaus P Ashburn, Anna C Snavely, Brennan E Paradee, James C O'Neill, Jason P Stopyra, Simon A Mahler

Abstract

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.

Trial registration: ClinicalTrials.gov NCT02056964.

Keywords: HEART Pathway; accelerated diagnostic protocol; acute coronary syndrome; geriatric; older adults.

Conflict of interest statement

Ms. Paradee and Dr. O'Neill have no conflicts. Dr. Ashburn receives funding from NHLBI (T32HL076132). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Dr. Snavely receives funding from Abbott and HRSA (1H2ARH399760100). Dr. Stopyra receives research funding from NCATS/NIH (KL2TR001421), HRSA (H2ARH399760100), and Roche Diagnostics. Dr. Mahler receives funding/support from Roche Diagnostics, Abbott Laboratories, Ortho Clinical Diagnostics, Siemens, Grifols, Pathfast, Quidel, Genetesis, Cytovale, and HRSA (1H2ARH399760100). He is a consultant for Roche, Quidel, Abbott, Genetesis, Inflammatix, Radiometer, and Amgen and the Chief Medical Officer for Impathiq Inc.

© 2022 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals LLC on behalf of The American Geriatrics Society.

Figures

FIGURE 1
FIGURE 1
Pre‐ versus post‐implementation HEART Pathway outcomes by age group. MI, myocardial infarction

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