Prehospital risk stratification in patients with chest pain

Abstract

ObjectivesThe History, ECG, Age, Risk Factors and Troponin (HEART) Score is a decision support tool applied by physicians in the emergency department developed to risk stratify low-risk patients presenting with chest pain. We assessed the potential value of this tool in prehospital setting, when applied by emergency medical services (EMS), and derived and validated a tool adapted to the prehospital setting in order to determine if it could assist with decisions regarding conveyance to a hospital.MethodsIn 2017, EMS personnel prospectively determined the HEART Score, including point-of-care (POC) troponin measurements, in patients presenting with chest pain, in the north of the Netherlands. The primary endpoint was a major adverse cardiac event (MACE), consisting of acute myocardial infarction or death, within 3 days. The components of the HEART Score were evaluated for their discriminatory value, cut-offs were calibrated for the prehospital setting and sex was substituted for cardiac risk factors to develop a prehospital HEART (preHEART) Score. This score was validated in an independent prospective cohort of 435 patients in 2018.ResultsAmong 1208 patients prospectively recruited in the first cohort, 123 patients (10.2%) developed a MACE. The HEART Score had a negative predictive value (NPV) of 98.4% (96.4–99.3), a positive predictive value (PPV) of 35.5% (31.8–39.3) and an area under the receiver operating characteristic curve (AUC) of 0.81 (0.78–0.85). The preHEART Score had an NPV of 99.3% (98.1–99.8), a PPV of 49.4% (42.0–56.9) and an AUC of 0.85 (0.82–0.88), outperforming the HEART Score or POC troponin measurements on their own. Similar results were found in a validation cohort.ConclusionsThe HEART Score can be used in the prehospital setting to assist with conveyance decisions and choice of hospitals; however, the preHEART Score outperforms both the HEART Score and single POC troponin measurements when applied by EMS personnel in the prehospital setting.

Chest Pain Management Using Prehospital Point-of-Care Troponin and Paramedic Risk Assessment

“…Several studies have shown that paramedic risk assessment and point-of-care troponin testing are feasible in the prehospital setting, with minimal delays in transport times to the hospital. [5][6][7][8][9][10] In some studies, prehospital blood draws for immediate testing on arrival to the ED have been associated with reduced ED length of stay, results that might be extrapolated to prehospital point-of-care troponin testing. 6,8 In the Netherlands, 1 trial using prehospital risk assessment and serial point-of-care troponin testing (via 2 ambulance visits) categorized 28% of the cohort as low risk, with these patients referred to other health services rather than being transported to the ED with similar outcomes.…”

Unscheduled care pathways in patients with myocardial infarction in Scotland

“…Furthermore, NHS24 telephone triage and PCOOH do not have access to diagnostic tools such as troponin and ECG. Pre-hospital use of these investigations by emergency medical services has been shown to aid conveyance decisions,28 but further research is needed as to whether access to point-of-care troponin in ambulance services and PCOOH would improve outcomes and reduce referrals. Research is also needed to examine the characteristics and outcomes of patients that each service discharges as well as those that are referred to other UC services for further assessment, particularly if telephone triage is to become the single point of entry for those attempting to access UC.…”

The potential for improvement of quality parameters and reduction of costs in the current Non-ST Elevation Myocardial Infarction logistics

“…In an intervention centre, time from admission to revascularisation was shorter than in a general hospital [8 days (5)(6)(7)(8)(9)(10)(11)(12) vs. 10 days (7-14), p = < 0.001]. Total length of stay was shorter in an intervention centre compared to a general hospital [16 days (12)(13)(14)(15)(16)(17)(18)(19)(20)(21) vs. 18 days (14-23), p < 0.001]. In MACE, no difference was found between the hospitals [9.2% vs. 10.8%, p = 0.481].…”

“…An example of such scores are the preHEART and the modi ed HEART pathway which use the patients' history, ECG, risk factors and a Point-of-Care (POC) Troponin. (15,16) These scores provide paramedics with the opportunity to make a strati cation of likelihood for patients with undifferentiated chest pain for having a NSTEMI. The likelihood ratio of combined risk scores for risk strati cation in suspected NSTEMI patients are currently better then standalone history, ECG and, POC-Troponin alone.…”