Clinical Decision Support using the HEART Pathway

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Chest pain is one of the most common complaints in the emergency department and historically most patients with chest pain were admitted for further evaluation. Comprehensive evaluation of chest pain from the emergency department costs 10 to 13 billion dollars annually (1). The HEART score(4) and subsequently HEART pathway(1) were created and have successfully helped stratify chest pain and aid in disposition decisions, especially identifying patients for discharge avoiding admission for further evaluation. While the original HEART Score(4) is effective and has been internally and externally validated, the HEART Pathway’s serial troponins have a higher sensitivity and NPV for adverse cardiac events then the HEART score alone(1). Especially important there were no major cardiac events in patients identified for early discharged at 30 days in the HEART Pathway(1).


Smulowitz et al. took this one step further by taking the successful HEART pathway and building it into their EHR as a clinical decision support tool in their community practice comparing their management of chest pain prior to and after implementation. They initially flagged patients who had a chief complaint of chest pain, a negative troponin and were 30 years or older. Once flagged the provider was prompted to use the tool on the department screen, in the individual patient record and prior to signing the patient chart they had to choose to enroll, decline, or ignore. If the provider chose to use the pathway they were then prompted to calculate a heart score. If the patient had a heart score less then 3 and negative serial troponins they could be discharged with clinician discretion and after a formal shared decision-making discussion. After implementing their tool they did have a statistically significant decrease in admissions for chest pain. Of the total flagged patients, the tool was used 1029 times, it was ignored 230 (~18%) times. They had one major cardiac event in their early discharge group after implementation and this was attributed to physician judgement instead of a failure of the Pathway.


The emergency department is a complex and fast moving environment and chest pain is a costly, high liability complaint. A recent review by Bennetta and Hardiker(2) showed that there is significant room for improvement in the literature for CDS use in the Emergency Department. While this paper suffers from some of the shortcomings identified by Benneta and Hardiker, Smulowitz et al managed to successfully integrate a high impact clinical decision tool into their EHR and their practice. They demonstrate successful use of a “flag and nag” system could be refined applied and more widely and robustly studied in emergency departments in the future.

1. Mahler, S. A., et al. “The HEART Pathway Randomized Trial: Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge.” Circulation: Cardiovascular Quality and Outcomes, vol. 8, no. 2, 2015, pp. 195–203., doi:10.1161/circoutcomes.114.001384.

2. Bennett, Paula, and Nicholas R. Hardiker. “The Use of Computerized Clinical Decision Support Systems in Emergency Care: a Substantive Review of the Literature.” Journal of the American Medical Informatics Association, 2016, doi:10.1093/jamia/ocw151.

3. Smulowitz, Peter B., et al. “Impact of Implementation of the HEART Pathway Using an Electronic Clinical Decision Support Tool in a Community Hospital Setting.” The American Journal of Emergency Medicine, vol. 36, no. 3, 2018, pp. 408–413., doi:10.1016/j.ajem.2017.08.047.

4. A.J. Six, B.E. Backus, and J.C. Kelder” Chest pain in the emergency room: value of the HEART score” Neth Heart J. 2008 Jun; 16(6): 191–196.

Submitted by Colton Hood