Effect of a HEART Score Best Practice Alert on Discharge Decisions and Outcomes of Patients Presenting to an Emergency Department with Chest Pain

Contemporary evaluation of chest pain (CP) utilizes a high-sensitivity troponin (hsTn) accelerated diagnostic protocol (ADP). Whether the addition of a bioclinical risk score such as the HEART score improves performance of a hsTn ADP is not clear. To determine the effect of an automated best practice alert (BPA) that guided capture of the HEART score on emergency department (ED) discharge decision-making and outcomes when added to a hsTn ADP. Retrospective cohort study of patients evaluated for CP in a 6 month period before and 10-month period following launch of a HEART score BPA in May 2022. Discharge percentages and 30-day major adverse cardiac event (MACE) rates were determined for the pre- vs. post-BPA cohort and stratified by both peak hsTnT value and HEART score. Compared to the pre-BPA cohort (n = 4438), post-BPA (n = 6794) with a completed HEART score had a higher rate of ED discharge (5.5% vs. 3.6%, p < 0.001). Patients with low (≤3) risk HEART scores had significantly lower (1.6% vs. 0.6%, p = 0.001) and patients with high-risk scores had significantly higher (1.6% vs. 6.6%, p < 0.001) rates of 30-day MACE vs. pre-BPA. The relationship of HEART score to MACE had the most discriminatory power in patients with peak hsTnT 12/51 ng/dL (3.9% vs. 6.7%, p < 0.028). The addition of a HEART score BPA to a hsTnT ADP was associated with a higher rate of discharge and improved risk stratification of 30-day MACE among patients for whom a discharge disposition was made, particularly among patients with moderate elevations (12-51 ng/dL) of hsTnT.