A 42-year-old female, presents with chest pain
Assignment Details: Our patient, a 42-year-old female, presents with chest pain. According to the American Heart Association (AHA) and the American College of Cardiology (ACC) implemented guidelines this year, and stated that the patient’s evaluation and work-up should be based on a cardiac risk algorithm, in which there are many (Buelt, et al., 2023). These authors recommend using the HEART pathway. The HEART pathway was designed as an accelerated diagnostic protocol on chest pain (Snavely, et al., 2021). It is a very easy to understand design, categorizing 5 main points: History, Age, EKG, Risk Factors, and Initial Troponin Levels (Nedea, 2020). Each category is given a 0 – 2 grade; 0 being a low-no risk, and 2 being high risk. Each category does not have equal weight. Troponin is heavily weighted, with the other factors weighted equally. If troponin is a “0,” and the HEART total score is 3 or less, than our patient can be discharged once the troponin is rechecked in 3 hours and is still zero. However, if the troponin is more than normal, then a cardiology consult and admission is recommended.
Our patient does have diabetes mellitus (DM) which gives her a “+1” on the HEART scale for history risk factors; but does not warrant hospital admission by itself (Nedea, 2020). In fact, if her troponin level and EKG are normal, has no personal history of heart defects, coronary artery disease, stroke, or infarct, then she would be of “low” risk for a myocardial infarct (MI).
The reason an assessment algorithm is important in patients with chest pain, is that 6 – 9 million patients visit an emergency department annually with chest pain, and costs healthcare systems $10 – $13 billion annually (Snavely, et al., 2021). The HEART risk algorithm has been studied for years, and shows to decrease hospitalizations by 6.6%, coincides with a very low death rate among those discharged as “low-risk” (0.4% for women and 0.5% for men), and a low MI rate among low-risk patients regardless of sex or race.
Lastly, our text does not say our patient is a smoker; but general smoking cessation guidelines from the U.S. Preventative Services Task Force suggest that all medical providers ask each patient about tobacco use, advising smoking cessation, provide behavioral and/or pharmacological support for cessation (Dakkak, 2021). However, studies do show that varenicline (Chantix) is more effective than both nicotine replacement and bupropion.
Buelt, A., Kennady, J., & Arnold, M. (2023). Chest pain evaluation: Updated guidelines from the AHA/ACC. American Family Physician, 107(2), 204-206.
Dakkak, M. (2021). Medications for smoking cessation: Guidelines from the American Thoracic Society. American Family Physician, 103(6), pp. 380-381.
Nedea, D. (2020, October 20). HEART pathway acute chest pain for early discharge. MDApp. https://www.mdapp.co/heart-pathway-acute-chest-pain-for-early-discharge-calculator-577/
Snavely, A. C., Hendley, N., Stopyra, J. P., Lenoir, K. M., Wells, B. J., Herrington, D. M., Hiestand, B. C., Miller, C. D., & Mahler, S. A. (2021). Sex and race differences in safety and effectiveness of the HEART pathway accelerated diagnostic protocol for acute chest pain. The American Heart Journal, 232, 125-136. https://doi.org/10.1016/j.ahj.2020.11.005
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