Please select the eligibility criteria that correspond to the clinical trial below.
Title: Efficacy Evaluation of the HEART Pathway in Emergency Department Patients With Acute Chest Pain
Brief Summary: Our research will examine a chest pain care strategy, called the HEART pathway, which is designed to correctly identify Emergency Department patients at high-risk for cardiovascular events, likely to benefit from further testing, and patients at very-low-risk for cardiovascular events, who may be safely discharged home. By using an individual's risk assessment to determining testing, we hope to improve the quality and efficiency of the care delivered to Emergency Department patients with chest pain. Our study will determine if the HEART pathway, which combines a clinical decision rule, the HEART score, and two serial troponin measurements, will reduce stress testing and cardiovascular imaging, decrease hospital length of stay, and reduce cost compared to usual care, while maintaining safety.


Options:
A: Inclusion Criteria:

* Age greater than or equal to 21 years
* Chest discomfort or other symptoms consistent with possible ACS
* The treating physician feels the patient could be discharged home if cardiac disease was excluded

Exclusion Criteria:

* New ST-segment elevation in contiguous leads on any electrocardiogram (\>/= 1 mV)
* Unstable vitals signs: symptomatic hypotension at the time of enrollment (systolic \< 90 mm Hg), tachycardia (HR\>120), bradycardia (HR\<40), and hypoxemia (\<90% pulse-oximetry on room air or normal home oxygen flow rate)
* Terminal diagnosis with life expectancy less than 1 year
* A non-cardiac medical, surgical, or psychiatric illness determined by the provider to require admission, increase risk of objective cardiac testing, or prevent immediate discharge following negative testing.
* Prior enrollment
* Incapacity or unwillingness to provide consent and comply with study procedures
* Non-English speaking

Sub-study I \& II

Inclusion Criteria:

* ED attending physicians

Exclusion Criteria:

* ED attending physicians who decline to participate
B: Inclusion Criteria:

1. Age ≥ 75 years
2. Admitted for in-hospital treatment for an internal medicine disease
3. Green tag triaged upon arrival in the ED

Exclusion Criteria:

1. Previous participation in this trial
2. Participation in other clinical trials
3. No QDU beds available
4. Subject does not have a Danish Civil Registration Number (CPR).
5. Subject resides abroad
6. Requires help using the toilet in daily life
7. Patients not aware of date, time and location, or their own data (name, birth date)
8. Informed consent cannot be obtained
C: Inclusion Criteria:

* Age greater than or equal to 18 years
* Chest discomfort or other symptoms consistent with possible ACS
* TIMI risk score ≥ 1 or physician impression\* of intermediate or high likelihood symptoms represent ACS
* Patient requires an inpatient or observation unit evaluation for their chest pain
* The treating physician feels the patient could be discharged home if cardiac disease was excluded
* ED attending feels patient is safe for observation unit care\*\*

Exclusion Criteria:

* Initial troponin I \> 1.0 ng/ml
* New ST-segment elevation (≥1mV) or depression (≥2 mV)
* Contra-indications to MRI (listed below)
* Unable to lie flat
* Hypotension (systolic \< 90 mm Hg)
* Renal insufficiency (estimated GFR \< 45 cc/min) or end stage renal disease
* Life expectancy less than 3 months
* Patient refusal of medical record review and follow-up at 30 days
* Pregnancy
* Liver, heart, or kidney transplant
* Chronic liver disease
* Unable to speak English or Spanish
* The ED attending feels that cardiac catheterization is indicated
* The ED care provider intends to order a CT coronary angiogram

(\*)Physicians are encouraged to use the 2007 ACC/AHA guidelines for the management of patients with NSTE ACS as a framework for this assessment.(1)

(\*\*)These patients should generally not be considered for observation unit care: PCI / CAGB in past 6 months, multiple stents, multiple prior MIs

Contraindications to MRI: (Pacemaker, defibrillator, cerebral aneurysm clips, metallic ocular foreign body, implanted devices, claustrophobia)
D: Inclusion Criteria:

* Age greater than or equal to 18 years of age at the time of enrollment
* Chest discomfort or other symptoms consistent with possible Acute Coronary Syndrome (ACS) as indicated by the treating physician after obtaining an Electrocardiogram (ECG) and cardiac biomarkers for the patient's evaluation
* Patient requires an inpatient evaluation for their chest pain
* The treating physician feels the patient could be discharged home if cardiac disease was excluded
* Thrombolysis in Myocardial Infarction (TIMI) risk score ≥ 2 OR physician clinical impression of intermediate or high likelihood that the symptoms represent ACS
* Negative pregnancy test (if sexually active, female, and of childbearing age)

Exclusion Criteria:

* Initial troponin I \> 1.0 ng/ml
* New ST-segment elevation on any electrocardiogram (≥ 1 mV)
* New ST-segment depression on any electrocardiogram (≥ 2 mV)
* Unable to lie flat
* Hypotension (systolic \< 90 mm Hg)
* Contra-indications to MRI(Pacemaker, defibrillator, cerebral aneurysm clips, metallic ocular foreign body, implanted devices, claustrophobia)
* Patient refusal of medical record review and telephone follow-up at 30 days
* Terminal diagnosis with life expectancy less than 3 months
* Pregnancy per patient report or positive pregnancy test (Center for Medicare \& Medicaid Services (CMS) exclusion criteria)
* Renal insufficiency(done prior to enrollment)or end stage renal disease
* Chronic liver disease (ex. hepatitis, cirrhosis)
* History of liver, heart, or kidney transplant

Answer: A