Safety and Effectiveness of the High-Sensitivity HEART Pathway Safely Across Age Groups in Patients With Suspected Acute Coronary Syndrome

The high-sensitivity HEART Pathway (hs-HP) is a risk stratification algorithm for Emergency Department (ED) patients with chest pain. However, its diagnostic performance across age subgroups is unknown. We conducted a subgroup analysis of the 5-site hs-HP implementation study. Pre-implementation (1/2019-4/2020) the traditional HEART Pathway was used with contemporary troponins. Postimplementation (11/2020-2/2022) the hs-HP was used with high-sensitivity troponins to risk-stratify patients into rule-out, observation, and rule-in groups. Patients were classified as young (aged: 18 to 45), middle-aged (46 to 64), or older (≥65). Effectiveness and safety outcomes included 30-day hospitalizations and 30-day all-cause mortality or myocardial infarction (MI), respectively. Multivariable logistic regression was used to compare outcomes pre- vs. postimplementation within age subgroups. The 26,126 patients accrued (12,317 pre- and 13,809 postimplementation) were 35.3% non-White and 52.7% female. Postimplementation, hospitalizations decreased 18.1% among the older patients (70.6% vs. 52.5%; aOR 0.47, 95% CI, 0.42 to 0.52), 18.2% in middle-aged (50.0% vs. 31.8%; aOR 0.48, 95% CI, 0.44 to 0.52), and 7.5% among young patients (20.1% vs. 7.6%; aOR 0.69, 95% CI, 0.59 to 0.76). In older patients, 30-day death or MI occurred in 12.9% (497/3,861) postimplementation vs. 13.5% (482/3,571) preimplementation (aOR 1.02; 95% CI, 0.89 to 1.18). In middle-aged patients, 7.0% (382/5,495) had 30-day death or MI postimplementation vs. 7.5% (395/5,257) preimplementation (aOR 1.01; 95% CI, 0.87-1.18). Finally, 30-day death or MI occurred in 1.5% (66/4,453) of young patients postimplementation vs. 2.0% (71/3,489) preimplementation (aOR 1.01; 95% CI 0.69 to 1.48). In conclusion, the hs-HP significantly reduced hospitalizations across all age groups of patients with chest pain, without increasing 30-day adverse events.