Maximizing Safety, Value, and Patient Preferences for Treating Chest Pain

“We need to attend to… patients in a way that is both safe and patient-centered.”

Traditionally, when patients come to an emergency department (ED) with chest pain, the hospital’s usual first course of action is to admit them. You don’t want to miss a potential heart attack, the thinking goes. The problem: most people aren’t actually having a heart attack. And it turns out that admitting everybody for a battery of tests is expensive, costing the healthcare system more than $3 billion annually, and has no benefit to patients.

This is the problem that Simon A. Mahler, M.D., is confronting. Dr. Mahler, professor and vice chair of research at Wake Forest University School of Medicine’s Department of Emergency Medicine, is using AHRQ funding to test ways to classify risk among patients with chest pain. “We do all this workup on patients, and it turns out that less than 10 percent of them are having a heart attack,” he says. “Most of the time we do this without even knowing what patients want. We need to attend to these patients in a way that is both safe and patient-centered.”

An emergency physician by training, Dr. Mahler was drawn to cardiovascular care after seeing too many patients being admitted unnecessarily. He joined a team at Wake Forest that tested a Dutch system for scoring patients in the ED with chest pain and placing them into risk categories. 

Dr. Mahler modified the Dutch system by developing it into an accelerated diagnostic protocol at Wake Forest to identify low-risk ED patients with acute chest pain who could be discharged quickly. Refinement of this approach allowed the Wake Forest hospital to reduce its admission rate for patients presenting at the ED with chest pain from 80 percent in 2010 to 35 percent currently. Although that achievement was impressive, Dr. Mahler sought an AHRQ grant to determine if even more patients can avoid admission. “The dilemma is what to do with moderate-risk patients,” he says. 

Dr. Mahler received his 5-year AHRQ grant in 2023 to test a strategy he calls CARE, for Cardiovascular Ambulatory Rapid Evaluation. He aims to find out if moderate-risk patients can be sent home safely and receive outpatient clinic follow up within 72 hours in lieu of being admitted immediately. He and his team will evaluate utilization rates, safety, and patient preference. His project ends January 31, 2028.

Principal Investigator: Simon A. Mahler, M.D.
Institutions: Wake Forest University School of Medicine
Grantee Since: 2023
Type of Grant: Research Project Grant (R01)

Related AHRQ Resource

• Topic: Heart Disease and Health.