Clinical impact of an emergency fast-track pathway on early intervention and outcomes in acute coronary syndrome: a prospective cohort study

Acute coronary syndrome (ACS) is a major cause of morbidity and mortality worldwide, and clinical outcomes are highly dependent on rapid diagnosis and treatment. Although guidelines emphasize time-sensitive targets, delays remain common in real-world emergency care. Evidence on the effectiveness of structured fast-track pathways, particularly in Asian populations and across the full ACS spectrum, is limited. To evaluate the impact of an emergency fast-track pathway on process-of-care metrics and short-term clinical outcomes in ACS patients. We conducted a prospective cohort study including 870 consecutive patients with ACS (STEMI, NSTEMI, and unstable angina) presenting to the emergency department from January 2022 to December 2023. Patients managed via the fast-track pathway (n = 438) were compared with those receiving conventional care (n = 432). The primary endpoints were door-to-electrocardiogram (ECG) time, door-to-balloon (D2B) time, and time to first antiplatelet therapy. Secondary endpoints included in-hospital major adverse cardiovascular events (MACE) and 30-day outcomes. Confounding was minimized using propensity score–based inverse probability of treatment weighting. The fast-track pathway significantly reduced door-to-ECG time (median 8 vs. 18 min, p < 0.001), D2B time in STEMI (68 vs. 102 min, p < 0.001), and time to first antiplatelet therapy (14 vs. 28 min, p < 0.001). Patients in the fast-track group had a lower incidence of in-hospital MACE (6.6% vs. 11.6%, p = 0.011), fewer recurrent myocardial infarctions (2.5% vs. 5.1%, p = 0.046), and shorter hospital stay (7 vs. 9 days, p < 0.001). At 30 days, the composite endpoint of death, recurrent myocardial infarction, or unplanned revascularization was reduced (8.7% vs. 13.9%; HR 0.61, 95% CI 0.42–0.90; p = 0.011). Major bleeding rates were similar between groups. Emergency fast-track pathways significantly improve treatment timeliness and clinical outcomes in ACS without increasing bleeding risk. These findings provide real-world evidence supporting the broader integration of fast-track protocols into emergency care.