Updated PVH pathway for low-risk chest pain reflects advances in testing, guidelines

A multidisciplinary team of clinicians has updated and launched a new pathway for patients who present at Platte Valley with chest pain but who are at low risk for a major adverse cardiac event.

The new process reflects both advances in testing and updates to best-practice guidelines to ensure patients receive the precise level of care they need.

First, let’s talk about what remains the same: For patients 18 years and older who present with symptoms of atraumatic truncal pain (chest, upper belly, back, shoulder, neck and jaw), shortness of breath, weakness, palpitations, syncope, nausea, vomiting, diaphoresis or confusion, an EKG will be performed, stamped and read by a physician within 10 minutes of their arrival. Blood work also is drawn at the time of the rapid EKG and a troponin is sent, which is used to determine injury to the heart muscle.

Now, for what’s changed: We recently reached out to two physician champions of this effort, David Baldwin, DO, Internal Medicine, and Sarah White, MD, Emergency Medicine, to explain the update and how following the new pathway improves care.

Q: What has changed in the process of caring for these patients?

Dr. White: “Previously, all patients who met rapid EKG criteria underwent a chest pain ‘rule out.’ In rolling out our new pathway, a patient is only moved off of the low-risk chest pain pathway if the HEART score is greater than six, the patient’s history is concerning for a heart attack, or the EKG is concerning for heart attack. We also now have the high-sensitivity troponin assay.”

Dr. Baldwin: “The high-sensitivity troponin assay takes a more prominent role in this new pathway and can help us make thoughtful decisions regarding a patient's risk for a major adverse cardiac event, what we call MACE. Additionally, if admission to the hospital is not recommended, we found that we can get reliable outpatient follow up with our cardiology team within a recommended timeframe of 30 days.”

Q: Why was a change needed?

Dr. White: “To quickly provide advanced, urgent care where it’s needed, and not where it isn’t. Many people come to the Emergency Department with complaints that will trigger a rapid EKG. It is important that we abruptly identify those who are more high risk of having a heart attack.

“If a patient remains on the low-risk chest pain pathway, the physician typically finds that their symptoms are due to a reason that is not cardiac and a chest pain rule out in the ED is not required. This will not only save the patient time and money, but also will allow the ED to be more efficient and capable of quickly caring for patients who arrive seeking medical attention.”

Dr. Baldwin: “To better reflect advances in care. The HEART score was developed before high-sensitivity troponin testing, and we needed to update our process with this improvement.

“Further, our previous protocol was based on old guidelines that said if an intermediate-risk patient was not admitted to the hospital, they needed to have 72-hour follow up in a cardiology office to consider stress testing. But studies done after those older guidelines found that scheduling a follow-up appointment in just three days was both unlikely and unnecessary. We can safely recommend outpatient follow up within 30 days for those intermediate-risk patients, which is in agreement with the most recent guidelines from the AHA/ACC.”

Q: What do you want Platte Valley’s physician community to know about the heart care this hospital provides?

Dr. Baldwin: “We put a lot of thought and energy into being considerate about how we approach and care for patients with chest pain. Between the emergency medicine, hospitalist and cardiology teams, I think we have mapped out a good strategy for taking care of these patients to the best of our ability.”

Dr. White: “I feel fortunate to be the ED representative for the cardiovascular program at Platte Valley. In the few years I have been involved in the program, I have seen it grow into a valuable resource for our ever-expanding community. Now we not only manage and treat cardiac illnesses and injuries, but also incorporate care from the interventional radiology team and electrophysiologists. I fully expect Platte Valley to continue to be a center of excellence for cardiac care, and I am excited to see how it will grow next.”

In addition to Drs. Baldwin and White, hospital and physician leadership would like to recognize Chris Cannon, MD, medical director of the Cath Lab and Chest Pain Program, Christy Chaudhuri, MD, Internal Medicine, Candace Harrod, MD, Emergency Medicine, Marissa Hughbanks, MD, Internal Medicine, Ryan Klemt, MD, Emergency Medicine, and Jessica Mahoney, RN, stroke and chest pain coordinator, for their thoughtful and devoted leadership in this collaboration to improve patient care.

Please click the button below to see the new low-risk chest pain pathway at Platte Valley.

Physicians with questions about the care provided to these patients can contact any member of this collaboration listed above.