Acute chest pain decisions from the HM17 HEART workshop

Acute chest pain is a frequent emergency department presentation, and the HEART Score Workshop at HM17 focused on assessing patients whose initial evaluation suggests a low likelihood of serious coronary disease. The Society of Hospital Medicine’s meeting at Mandalay Bay Resort and Casino in Las Vegas, held on 1–4 May 2017, gave hospitalists a structured way to combine history, ECG findings, age, risk factors and troponin results rather than relying on an unstructured impression of risk.

Managing acute chest pain in low-risk patients is never simply a matter of sending everyone home. Even a reassuring score must fit the person’s symptoms, examination, comorbidities and access to follow-up. That combination matters particularly in Australia, where metropolitan emergency departments are crowded, regional hospitals cover vast catchments, and patients may face long journeys after discharge.

Understanding the HEART score

Several chest-pain scores can support an emergency department decision, but they answer different questions and were developed in different populations. HEART estimates the six-month risk of major adverse cardiac events in undifferentiated chest pain; EDACS has been validated in Australian cohorts, while TIMI is more often applied after acute coronary syndrome is suspected.

A HEART result of 0–3 is commonly treated as low risk, 4–6 as intermediate and 7 or more as high risk. These bands support a conversation about observation, further testing and admission, but they are not stand-alone rules for discharge. A low score cannot cancel a concerning story, an abnormal examination or an ECG pattern outside the assumptions of the original validation, and it should not replace evaluation of known coronary disease or special populations.

Australian pathways should also specify how repeat troponins, serial ECGs and clinical deterioration change the assessment. Without those instructions, low risk can become a label attached too early. The score is most useful when the treating clinician can explain why each component was awarded and which findings would override the total.

Applying the score at the bedside

The five elements of HEART are not interchangeable. History asks about exertional pressure, radiation, associated dyspnoea and previous cardiovascular disease. The ECG component considers the presence or absence of ST-segment deviation, while age, risk factors such as smoking or diabetes, and an initial troponin each add to the total.

Troponin interpretation needs the assay, timing and clinical context. A single below-threshold result may support a low-risk pathway when the ECG is non-diagnostic, symptoms are improving and a validated protocol applies; otherwise serial high-sensitivity testing is safer. Comparing values rather than treating any negative result as conclusive helps detect a rise and/or fall in troponin.

Intermediate-risk patients need a defined destination: monitored observation, inpatient admission, stress imaging or coronary CT angiography may be appropriate depending on the presentation and local capability. High-risk scores usually demand urgent cardiology review and inpatient care. Even with a low score, persistent symptoms, syncope, instability or suspicious ECG changes should trigger escalation rather than outpatient follow-up.

Fitting the pathway into Australian care

Australian emergency departments, including major services in Melbourne and Sydney, often manage high volumes of potentially low-risk chest-pain presentations. Short-stay units and emergency department fast-track services can preserve inpatient beds, but they require staffing, repeat testing and discharge pathways that work around the clock.

Access and charges also differ by setting. Eligible patients admitted to a public hospital generally pay no Medicare charge for their hospital treatment under the National Health Act 2010 (Cth), while private insurance and out-of-pocket costs shape choices in the private market. Clear communication about tests, admission and follow-up reduces financial uncertainty.

Place creates another layer. Hospitals in northern and regional Australia may use telehealth, retrieval teams and the Royal Flying Doctor Service, whereas patients in cities usually have more nearby imaging and specialist options. State ambulance services reached through 000 apply their own protocols, so a regional pathway may begin before a hospital assessment is possible.

Other conditions can complicate the score. For hypertensive admissions, HM17 also offered 2017 hypertension guidance on applying the AHA/ACC update. Australian teams should interpret that overseas material alongside current local protocols, especially when renal function, orthostasis or heart failure affects safe disposition.

Turning education into practice

Education is most useful when it changes the next clinical decision. For hospitalists unable to attend Las Vegas, the HM17 conference resources provide context for the meeting’s continuing medical education, research and best-practice focus. The conference’s professional networking also offered a way to compare local implementation problems with colleagues facing different staffing and testing arrangements.

At the bedside, that learning can become a standard chest-pain bundle: a documented HEART calculation, senior discussion for intermediate-risk cases, explicit troponin and ECG protocols, and a discharge summary that reaches the general practitioner and patient. Local audit should examine outcomes as well as throughput, since fewer admissions are not meaningful if serious coronary disease is missed.

Managing comorbidities and medication risks

Comorbidity is where apparently low-risk patients can become medically complex. Hypertension may have already produced target-organ damage, and diabetes or chronic kidney disease can make a reassuring troponin less convincing. Medication review should cover adherence, recent changes and over-the-counter products; antacids or anti-inflammatory painkillers taken for indigestion may mask the pattern of symptoms without explaining it.

A related conference review on new oral anticoagulants illustrates the need to translate trial evidence into safe inpatient prescribing, particularly for older patients with atrial fibrillation and impaired renal function. Direct oral anticoagulants have their own bleeding risks, and current TGA-approved product information and Pharmaceutical Benefits Scheme conditions determine access. Such treatment is relevant to a coexisting anticoagulation indication, not as a routine response to chest pain.

Medication safety extends beyond anticoagulation. Opioids can alter pain perception and mobilisation, while NSAIDs may worsen renal function or heart failure. The Australian Commission on Safety and Quality in Health Care’s medication-safety standards make reconciliation and clear handover central to avoiding harm during transfer from the emergency department to a ward.

Recommendations for safer assessment and discharge

A structured approach is valuable only when the final plan is safe and understandable. Recommendations for Australian practice include the following:

• Use HEART as an adjunct to clinical judgment, documenting symptoms, ECG findings, risk factors, troponin results and any reason to depart from the pathway.
• Specify the observation period and repeat-test schedule, including who reviews results and how an abnormal result triggers escalation.
• Arrange timely general-practitioner review, with earlier cardiology input when symptoms, examination or test results remain concerning.
• Provide written safety-netting advice about recurrent pressure pain, breathlessness, syncope and when to call 000 rather than wait for the next appointment.
• Make discharge achievable after long work shifts or long-distance travel by confirming medication supply, transport and access to urgent review in the patient’s local area.

These instructions should appear in the discharge letter as well as the patient’s written material. For regional patients, the general practitioner should know which tests were performed, what remains unresolved and how quickly symptoms require review. A low-risk result without reliable follow-up is not a complete low-risk pathway.

The lesson to remember

Since 2017, troponin assays and chest-pain pathways have developed, so current protocols should supersede historical conference thresholds. The lasting value of HM17 is therefore a disciplined sequence rather than a frozen decision rule: assess the patient, calculate the risk, challenge the result and plan what happens next.

The lesson to remember is simple: a low HEART score supports a low-risk decision only when the clinical assessment, the testing protocol and the follow-up plan agree. The number is useful when it makes those judgements clearer, and risky when it replaces them.