University of Lynchburg DMSc Doctoral Project Assignment Repository

University of Lynchburg DMSc Doctoral Project Assignment Repository


Emergency Medicine


Bernard Toney Jr., DMSc, PA-C



Objective: Chest pain is a prevailing complaint in outpatient settings (i.e. emergency department, urgent care) and accounted for 42.48 million visits from 2006 to 2016.1 It is the most common presenting symptom in patients presenting with Acute Coronary Syndrome (ACS). Coronary Artery Disease (CAD) is the “most common heart disease and leading cause of death in the United States.”1 Despite this, only 15-25% of patients with chest pain will have ACS requiring diligent clinician assessment and appropriate testing.1 Failure to adequately identify or manage ACS burdens the healthcare system and costs the average Americans $150 billion.2 Clinical decision pathways (CDPs) are evidence based tools used to assess patient risk and medical decision making. There are several Cardiac Risk Assessment CDPs available to use. This clinical review article will analyze the use of CDPs for outpatient evaluation of chest pain and examine if their application yields improved outcomes in diagnosis, prognosis, and healthcare spending.

Method: A PubMed literature search was conducted with search terms clinical decision pathway, HEART Score, Marburg Heart Score, ACS, chest pain, emergency department (ED), outpatient.

Results: CDPs were able to effectively identify cardiac ischemic causes of chest pain with studies concluding CDPs to be 99% to 100% sensitive for acute coronary syndrome.2 They were found to improve risk assessment and medical decision making, as patients with a Marburg Heart Score of ‘0’ only have a 3% chance of coronary artery disease.3. Németh et al.illustrated their ability to reduce healthcare cost associated by reducing unnecessary testing. Participants of the HEART Pathway trial saved $253 when CDPs were used to assist with medical decision making. Furthermore, CDPs were proven to avoid admission or further testing in 21.3% to 43% of eligible patients.9

Conclusion: Clinical decision pathways, such as the HEART Score, Marburg Heart Score, INTERCHEST, and HE-MACS are tools designed to risk stratify the likelihood of cardiac ischemia as the cause of chest pain.3 The implementation of CDPs resulted in improved medical decision making and patient outcome. Furthermore, research concluded that CDPs resulted in reduced hospital admissions, emergency department transfers, and decrease economic burden on patients and healthcare system.


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