Why use it

Prospective trials (Mahler 2015) showed the HEART Pathway reduces hospital admissions and length of stay by roughly half compared with usual care, with no missed MACE in low-risk patients. It is one of the most widely adopted accelerated diagnostic protocols for ED chest pain.

About

The HEART Pathway is an accelerated diagnostic protocol that combines the HEART score (History, ECG, Age, Risk factors, Troponin) with serial cardiac troponin measurements (at 0 and 3 hours). It identifies acute chest-pain patients at low risk for major adverse cardiac events (MACE) who can be safely discharged for outpatient evaluation, avoiding unnecessary admission and objective cardiac testing. A patient is classified "low risk / early discharge" only when the HEART score is 0–3 AND both serial troponins are below the assay limit; any other combination is "non–low risk".

When to use

Adult patients presenting to the ED with symptoms suggestive of acute coronary syndrome
Disposition decisions after an initial non-diagnostic ECG and troponin
When deciding whether serial troponins permit safe early discharge

Formula

Step 1 — HEART score (0–10): History (0–2) + ECG (0–2) + Age (0–2) + Risk factors (0–2) + initial Troponin (0–2) Step 2 — Serial troponins at 0 h and 3 h Low risk / early discharge = HEART score ≤ 3 AND both troponins negative

Pearls & pitfalls

Both criteria must be met for early discharge: HEART score ≤3 AND both serial troponins negative.
Use the initial (0-hour) troponin for the HEART score Troponin element; the second troponin is drawn at 3 hours.
A positive troponin at either time point makes the patient non–low risk regardless of the HEART score.
High-sensitivity troponin assays may allow a shorter (0/1-hour) sampling interval per local protocol.
The pathway supplements but does not replace clinical judgment and dynamic ECG interpretation.

Next steps

Low risk (HEART 0–3 AND both troponins negative): early discharge with outpatient follow-up; ~0.9–2% 30-day MACE. Non–low risk (HEART ≥4 OR any positive troponin): admit/observe, serial troponins, cardiology evaluation, consider objective testing.

Evidence

Mahler et al. (Circ Cardiovasc Qual Outcomes 2015) randomized trial: the HEART Pathway decreased objective cardiac testing, index admissions, and length of stay versus usual care, with zero MACE in patients identified for early discharge. Subsequent real-world implementation studies confirmed a 30-day MACE rate of roughly 0.9–1.7% in the low-risk group.

References

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;8(2):195-203. — link
Mahler SA et al. Use of the HEART Pathway with high-sensitivity cardiac troponin. Am Heart J. 2018;202:25-32. — link

HEART Pathway (Early Discharge)

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