Accuracy of pre-hospital HEART score risk classification using point of care versus high sensitive troponin in suspected NSTE-ACS

Dongen, Dominique N van; Fokkert, Marion J; Tolsma, Rudolf T; Sluis, Aize van der; Slingerland, Robbert J.; Badings, Erik A; Hof, Arnoud W J van 't; Ottervanger, Jan Paul

doi:10.1016/j.ajem.2019.158448

Cited by 18 publications

(13 citation statements)

References 20 publications

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“…These findings are comparable to those in the study by van Dongen et al. [ 7 ], which compared the HEART score based on POC troponin T versus hs-cTnT and found a different HEART score among 19% and different risk classification in low versus intermediate/high risk in only 2%. Another study by Aldous et al.…”

Section: Discussionsupporting

confidence: 89%

“…However, low-versus intermediate-/high-risk stratification was similar in 98%. These findings are comparable to those in the study by van Dongen et al [7], which compared the HEART score based on POC troponin T versus hs-cTnT and found a different HEART score among 19% and different risk classification in low versus intermediate/high risk in only 2%. Another study by Aldous et al [8] found similar results, showing the diagnostic accuracy of POC troponin I versus hs-cTnI results to be equal.…”

Section: Discussionsupporting

confidence: 89%

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URGENT 1.5: diagnostic accuracy of the modified HEART score, with fingerstick point-of-care troponin testing, in ruling out acute coronary syndrome

et al. 2021

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Background The HEART score is a validated risk stratification tool for chest pain patients presenting to the emergency department and was recently investigated for implementation in a pre-hospital setting. Fingerstick (capillary blood) point-of-care (POC) troponin testing enables quick measurements outside the hospital and seems easier to implement than the current venous blood sampling techniques. This study investigates the diagnostic accuracy of the modified HEART score, integrating fingerstick POC troponin testing, in ruling out acute coronary syndrome (ACS). Methods The data of 96 patients with chest pain, included in a study investigating a novel POC troponin device under development at the cardiac emergency department, were analysed retrospectively. Based on the patients’ admission data and capillary POC high-sensitivity troponin I (hs-cTnI) results, the modified HEART score was determined. The outcome measure, for evaluating the diagnostic accuracy of the modified HEART score, was the occurrence of ACS. Results Of the total study population, 33 patients (34%) were diagnosed with ACS. Seventeen patients (18%) were classified as low risk (0–3 points) and one patient (6%) in this group was diagnosed with ACS. The sensitivity and negative predictive value of the modified HEART score was 97.0 and 97.6%, respectively. Conclusion The modified HEART score, integrating capillary POC hs-cTnI results, is a promising tool for ruling out ACS in patients with chest pain presenting to the cardiac emergency department. These results encourage prospective investigation into the integration of fingerstick POC troponin testing in the modified HEART score in a pre-hospital setting.

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Section: Discussionsupporting

confidence: 89%

Section: Discussionsupporting

confidence: 89%

URGENT 1.5: diagnostic accuracy of the modified HEART score, with fingerstick point-of-care troponin testing, in ruling out acute coronary syndrome

et al. 2021

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“…These data match the findings of earlier studies, indicating that it does not really matter which troponin test is used: POC, I/T or high-sensitivity troponin, although the score was initially tested using standard troponin I/T measurements [4].…”

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confidence: 85%

Applying the HEART score is safe and saves

Appelman

Doevendans

2022

Neth Heart J

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Koper et al. performed an encouraging study (Urgent 1.5) to fine-tune the well-established HEART score [1], which was previously initiated and validated by the cardiologist Jacob Six. He and several PhD students looked at various aspects of the score, which was based on clinical intuition and experience to rule out an acute coronary syndrome (ACS). However, not every parameter (history, electrocardiogram [ECG], age, risk factor and troponin) or value (0, 1, 2) used to generate the score was validated initially. Yet the score outperformed all competitors, also because of patient selection. Interesting was the finding that calculation of the C-statistic to determine the weight of the 5 items times 3 values provided a 99% match [2]. The score was designed to rule out serious ACS in chest pain patients, who are swamping healthcare facilities. Therefore we focus on the low-risk group (HEART score 0-3) visiting the emergency department (ED) with potentially the largest gain for both patients and physicians. Even in low-risk patients many expensive diagnostic tests are performed which are time consuming and put the patient at risk during invasive procedures [3]. Even in the small study reported by Koper et al. [1], in patients with a low-risk score a very high sensitivity (97%) and negative predictive value (97.6%) are reported using the modified HEART score, and only one ACS was missed. Importantly, the study included a point-of-care (POC)-based test assessed by

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“…However, the original HEART score validation studies did not assess a second troponin measurement. 16 , 34 Although the currently used POC troponin measurement is deemed sufficient for pre-hospital risk stratification with the HEART score, 35 a high-sensitive POC measurement can even better risk stratify patients. Because of the lesser sensitivity of the current POC assay, our findings may overestimate the number of patients with a HEART score of ≤3 compared with what would be observed with a high-sensitivity assay.…”

Section: Discussionmentioning

confidence: 99%

Referral decisions based on a pre-hospital HEART score in suspected non-ST-elevation acute coronary syndrome: final results of the FamouS Triage study

Tolsma¹,

Fokkert

Dongen

et al. 2021

European Heart Journal. Acute Cardiovascular Care

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Aims Although pre-hospital risk stratification of patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) by ambulance paramedics is feasible, it has not been investigated in daily practice whether referral decisions based on this risk stratification is safe and does not increase major adverse cardiac events (MACE). In Phase III of the FamouS Triage study, it was investigated whether referral decisions by ambulance paramedics based on a pre-hospital HEART score, is non-inferior to routine management. Methods and results FamouS Triage Phase III is a non-inferiority study, comparing the occurrence of MACE before (Phase II) and after (Phase III) implementation of referral decisions based on a pre-hospital HEART score. In Phase II, all patients were risk-stratified and referred to the hospital; in Phase III, low-risk patients (HEART score ≤ 3) were not referred. Primary endpoint was MACE (acute coronary syndrome, revascularization, or death) within 45 days. A total of 1236 patients were included. Mean age was 63 years, 43% were female, 700 patients were included in the second phase and 536 in the third phase in which 149 low-risk patients (28%) were not transferred to the hospital. Occurrence of 45 days MACE was 16.6% in Phase II and 15.7% in Phase III (P = 0.67). Percentage MACE in low-risk patients was 2.9% in Phase II and 1.3% in Phase III. After adjustments for differences in baseline variables, the hazard ratio of 45 days MACE in Phase III was 0.88 (95% confidence interval 0.63–1.25) as compared to Phase II. Conclusion Pre-hospital risk stratification of patients with suspected NSTE-ACS, avoiding hospitalization of a substantial number of low-risk patients, seems feasible and non-inferior to transferring all patients to the hospital.

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Accuracy of pre-hospital HEART score risk classification using point of care versus high sensitive troponin in suspected NSTE-ACS

Cited by 18 publications

References 20 publications

URGENT 1.5: diagnostic accuracy of the modified HEART score, with fingerstick point-of-care troponin testing, in ruling out acute coronary syndrome

URGENT 1.5: diagnostic accuracy of the modified HEART score, with fingerstick point-of-care troponin testing, in ruling out acute coronary syndrome

Applying the HEART score is safe and saves

Referral decisions based on a pre-hospital HEART score in suspected non-ST-elevation acute coronary syndrome: final results of the FamouS Triage study

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