Presentation delivered at William G. Barsan Emergency Medicine Research Forum, Ann Arbor, April 27, 2016

1. Shared Decision Making Using the HEART Score and
a Visual Aid in Patients Presenting to the Emergency
Department with Chest Pain
Gregory Gafni-Pappas, DO, Susanne Demeester, MD, Michael Boyd,
MD, Arun Ganti, MD

2. Background
• Chest pain = 5 to 8% of ED volume
• Classically, these patients have been admitted or observed.

3. Times Are Changing
Many low-risk chest pain patients can be discharged.

4. The Goal
• Decrease unnecessary
hospitalization and testing
• Increase patient understanding and
satisfaction with their ED course.

5. The Baseline Practice
Accelerated Diagnostic Pathway, ADP

6. Accelerated Diagnostic Pathway

7. Background

8. Step 2: The HEART Score
• Prospectively and externally validated
–Utilizes 5 components:
• History
• EKG
• Age
• Risk factors
• Troponin

10. The Heart Score
• Backus, et al, 2008
Risk Level End Point Percentage Reached
Endpoint
Low 1/39 2.5%
Moderate 12/59 20.3%
High 16/22 72.7%
Neth Heart J. 2008 Jun;16(6):191-6.

11. Validation
• Backus, et. al 2013
– 2,440 Patients
– Low HEART Score
• MACE 6 weeks
– 1.7%
• Mahler, et. al 2011
– 1070 patients
– Low HEART Score
• MACE at 30 days
– 0.6%
Int J Cardiol. 2013 Oct 3;168(3):2153-8. Crit Pathw Cardiol. 2011
Sep;10(3):128-33

12. The Heart Score
• 30 days MACE is <1% in patients with a low HEART score
and two sets of troponins.

13. Background
x
22

14. x
55

15. Step 3: Visual Aid
• A visual tool is used to explain ED course, diagnosis,
and true risk.

16. Step 3: Visual Aid
• Educational
• Shared decision making
• Documents understanding

17. Shared Decision Making
• The visual aid is chosen based on the
patient’s calculated HEART score and
risk.

19. Background
• Chest pain = 5 to 8% of ED volume
• Classically, these patients have been admitted or observed.

20. Background
• Chest pain = 5 to 8% of ED volume
• Classically, these patients have been admitted or observed.

21. Implementation
1. HEART score calculated for patients with chest
pain and concern for ACS
2. 2 hour NSTEMI rule-out begins
3. Patient given corresponding visual aid (low,
moderate, high) after first troponin result
4. Patient and providers sign the visual aid.
Patient keeps a copy of the visual aid
5. Forms are scanned into chart

22. Results
2014 Pilot Phase
# Patients p/w
Chest Pain
4791 132
Admitted
Inpatient
148 (3.1%) 0
Direct to Cath 153 (3.2%) 0
EOC (Observation) 2716 (56.6%) 34 (25.7%)
Discharge 1927 (40.2%) 98 (74.24%)

23. Background
2014 Pilot Phase
# Patients p/w
Chest Pain
4643
(excludes Admit
and Cath)
132
Admitted Inpatient 148 (3.1%) 0
Direct to Cath 153 (3.2%) 0
EOC (Observation) 2716 (58.4%) 34 (25.7%)
Discharge 1927 (41.5%) 98 (74.24%)

24. Results
32.7% Reduction
in EOC Admissions
Fischer’s Exact Test
P < .0001

25. Key Points
• Chest pain is common
• Low-risk chest pain patients can safely
be discharged home provided they
understand their risk and have a plan for
follow-up.

26. Conclusions
• The HEART Score is a tool that can be
used to determine risk for 30 day
MACE.
• Visual aids improve provider and
patient understanding.
• All discharged patients still need time-
sensitive follow-up instructions.

27. References
1. Hess E. The chest pain choice decision aid: a randomized trial.Circ
Cardiovasc Qual Outcomes. 2012 May;5(3):251-9.
2. Six A et al. The HEART score for the assessment of patients with chest
pain in the emergency department: a multinational validation study. Crit
Pathw Cardiol. 2013 Sep;12(3):121-6.
3. Backus BE1, A prospective validation of the HEART score for chest pain
patients at the emergency department. Int J Cardiol. 2013 Oct
3;168(3):2153-8. doi: 10.1016/j.ijcard.2013.01.255. Epub 2013 Mar 7.
4. Mahler SA et al. The HEART Pathway Randomized Trial: Identifying
Emergency Department Patients With Acute Chest Pain for Early
Discharge. Circ Cardiovasc Qual Outcomes. 2015 Mar;8(2):195-203. doi:
10.1161/CIRCOUTCOMES.114.001384. Epub 2015 Mar 3.
5. Flynn D et al. Engaging patients in health care decisions in the
emergency department through shared decision-making: a systematic
review. Acad Emerg Med. 2012 Aug;19(8):959-67.
6. Neumar RW et al. Part 1: Executive Summary: 2015 American Heart
Association Guidelines Update for Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care. Circulation. 2015 Nov 3;132(18 Suppl
2):S315-67