Prehospital triage of patients with suspected non-ST-segment elevation acute coronary syndrome: Rationale and design of the TRIAGE-ACS study

Demandt, Jesse; Koks, Arjan; Haest, Rutger J; Heijmen, Eric; Thijssen, Eric J. M.; Otterspoor, Luuk C.; Veghel, Dennis van; Farissi, Mohamed El; Eerdekens, Rob; Vervaat, Fabienne E; Pijls, Nico H.J.; Veer, Marcel van‘t; Tonino, Pim A.L.; Dekker, Lukas; Vlaar, Pieter J.

doi:10.1016/j.cct.2022.106854

Cited by 4 publications

(5 citation statements)

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“…Additionally, a two recently conducted randomized trials by Camaro et al 18 and Dawson et al 19 demonstrated that prehospital rule‐out of ACS with a point‐of‐care troponin measurement in chest pain patient's notably reduced healthcare expenditure. However, there is not yet consensus on the most ideal form of prehospital triage as several methods are still in the early stages of development and trials are currently being conducted 20 . One such example is the highly anticipated TRIAGE‐ACS study which will be the first prospective study to investigate the impact of prehospital triage using the PreHEART score on time to final invasive diagnostics and treatment in patients with NSTE‐ACS in need of revascularization by transferring high risk patients directly to a PCI center and patients at a low risk of having an NSTE‐ACS to a non‐PCI center 20 …”

Section: Discussionmentioning

confidence: 99%

“…The existing triage of very-high risk patients to an intervention center is the only plausible reason for these differences in mortality. 20 One such example is the highly anticipated TRIAGE-ACS study which will be the first prospective study to investigate the impact of prehospital triage using the PreHEART score on time to final invasive diagnostics and treatment in patients with NSTE-ACS in need of revascularization by transferring high risk patients directly to a PCI center and patients at a low risk of having an NSTE-ACS to a non-PCI center. 20 Furthermore, the general efficiency of workflow and regional arrangements also yield improvement potential.…”

Section: Discussionmentioning

confidence: 99%

“…20 One such example is the highly anticipated TRIAGE-ACS study which will be the first prospective study to investigate the impact of prehospital triage using the PreHEART score on time to final invasive diagnostics and treatment in patients with NSTE-ACS in need of revascularization by transferring high risk patients directly to a PCI center and patients at a low risk of having an NSTE-ACS to a non-PCI center. 20 Furthermore, the general efficiency of workflow and regional arrangements also yield improvement potential. Attributes to the primary findings are most probably ad hoc scheduling issues at the intervention center combined with heart team deliberation in selected patients (e.g., postponement of treatment decision due to missing information).…”

Section: Discussionmentioning

confidence: 99%

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Direct admission versus interhospital transfer for revascularisation in non‐ST‐segment elevation myocardial infarction

Steenbergen

Demandt

Schulz

et al. 2023

Clinical Cardiology

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BackgroundThe differences in outcomes and process parameters for NSTEMI patients who are directly admitted to an intervention centre and patients who are first admitted to a general centre are largely unknown.HypothesisThere are differences in process indicators, but not for clinical outcomes, for NSTEMI who are directly admitted to an intervention centre and patients who are first admitted to a general centre.MethodsWe aim to compare process indicators, costs and clinical outcomes of non‐ST‐segment elevation myocardial infarction (NSTEMI) patients stratified by center of first presentation and revascularisation strategy. Hospital claim data from patients admitted with a NSTEMI between 2017 and 2019 were used for this study. Included patients were stratified by center of admission (intervention vs. general center) and subdivided by revascularisation strategy (PCI, CABG, or no revascularisation [noRevasc]). The primary outcome was length of hospital stay. Secondary outcomes included: duration between admission and diagnostic angiography and revascularisation, number of intracoronary procedures, clinical outcomes at 30 days (MACE: all‐cause mortality, recurrent myocardial infarction and cardiac readmission) and total costs (accumulation of costs for hospital claims and interhospital ambulance rides).ResultsA total of 9641 NSTEMI events (9167 unique patients) were analyzed of which 5399 patients (56%) were admitted at an intervention center and 4242 patients to a general center. Duration of hospitalization was significantly shorter at direct presentation at an intervention centre for all study groups (5 days [2–11] vs. 7 days [4–12], p < 0.001). For PCI, direct presentation at an intervention center yielded shorter time to diagnostic angiography (1 day [0–2] vs. 1 day [1–2], p < 0.01) and revascularisation (1 day [0–3] vs. 4 days [1–7], p < 0.001) and less intracoronary procedures per patient (2 [1–2] vs. 2 [2–2], p < 0.001). For CABG, time to revascularisation was shorter (8 days [5–12] vs. 10 days [7–14], p < 0.001). Total costs were significantly lower in case of direct presentation in an intervention center for all treatment groups €10.211 (8750–18.192) versus €13.741 (11.588–19.381), p < 0.001) while MACE was similar 11.8% versus 12.4%, p = 0.344).ConclusionNSTEMI patients who were directly presented to an intervention center account for shorter duration of hospitalization, less time to revascularisation, less interhospital transfers, less intracoronary procedures and lower costs compared to patients who present at a general center.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Direct admission versus interhospital transfer for revascularisation in non‐ST‐segment elevation myocardial infarction

Steenbergen

Demandt

Schulz

et al. 2023

Clinical Cardiology

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“…The TRIAGE-ACS study is a prospective, multicentre, two-cohort study and the design has been previously described. 20 The first cohort (n=500) is observational (standard care), while the second (interventional) cohort (n=500) includes patients who are stratified for direct transfer to either a PCI or a non-PCI centre based on their preHEART score. The cut-off for the preHEART score is based on previous data.…”

Section: Methodsmentioning

confidence: 99%

“…The mean interval until invasive diagnostics and revascularisation is approximately 4 days. 20 By performing triage with the preHEART score, we expect to reduce this time interval with 1 day. Accounting for missing data and patients without NSTE-ACS not undergoing invasive diagnostics, a total of 1000 (500 per cohort) patients are necessary to detect this effect of prehospital triage on the primary endpoint between the pre-interventional and post-interventional cohort at 80% power and a two-sided alpha-error of 5%.…”

Section: Sample Size Calculationmentioning

confidence: 99%

Prehospital risk assessment and direct transfer to a percutaneous coronary intervention centre in suspected acute coronary syndrome

Demandt,

Koks,

Sagel

et al. 2023

Heart

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ObjectivePrehospital risk stratification and triage are currently not performed in patients suspected of non-ST-segment elevation acute coronary syndrome (NSTE-ACS). This may lead to prolonged time to revascularisation, increased duration of hospital admission and higher healthcare costs. The preHEART score (prehospital history, ECG, age, risk factors and point-of-care troponin score) can be used by emergency medical services (EMS) personnel for prehospital risk stratification and triage decisions in patients with NSTE-ACS. The aim of the current study was to evaluate the effect of prehospital risk stratification and direct transfer to a percutaneous coronary intervention (PCI) centre, based on the preHEART score, on time to final invasive diagnostics or culprit revascularisation.MethodsProspective, multicentre, two-cohort study in patients with suspected NSTE-ACS. The first cohort is observational (standard care), while the second (interventional) cohort includes patients who are stratified for direct transfer to either a PCI or a non-PCI centre based on their preHEART score. Risk stratification and triage are performed by EMS personnel. The primary endpoint of the study is time from first medical contact until final invasive diagnostics or revascularisation. Secondary endpoints are time from first medical contact until intracoronary angiography (ICA), duration of hospital admission, number of invasive diagnostics, number of inter-hospital transfers and major adverse cardiac events at 7 and 30 days.ResultsA total of 1069 patients were included. In the interventional cohort (n=577), time between final invasive diagnostics or revascularisation (42 (17–101) hours vs 20 (5–44) hours, p<0.001) and length of hospital admission (3 (2–5) days vs 2 (1–4) days, p=0.007) were shorter than in the observational cohort (n=492). In patients with NSTE-ACS in need for ICA or revascularisation, healthcare costs were reduced in the interventional cohort (€5599 (2978–9625) vs €4899 (2278–5947), p=0.02).ConclusionPrehospital risk stratification and direct transfer to a PCI centre, based on the preHEART score, reduces time from first medical contact to final invasive diagnostics and revascularisation, reduces duration of hospital admission and decreases healthcare costs in patients with NSTE-ACS in need for ICA or revascularisation.Trial registrationNCT05243485.

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External validation of the preHEART score and comparison with current clinical risk scores for prehospital risk assessment in patients with suspected NSTE-ACS

Demandt,

Koks,

Sagel

et al. 2024

Emerg Med J

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BackgroundEmergency Medical Services (EMS) studies have shown that prehospital risk stratification and triage decisions in patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) can be improved using clinical risk scores with point-of-care (POC) troponin. In current EMS studies, three different clinical risk scores are used in patients suspected of NSTE-ACS: the prehospital History, ECG, Age, Risk and Troponin (preHEART) score, History, ECG, Age, Risk and Troponin (HEART) score and Troponin-only Manchester Acute Coronary Syndromes (T-MACS). The preHEART score lacks external validation and there exists no prospective comparative analysis of the different risk scores within the prehospital setting. The aim of this analysis is to externally validate the preHEART score and compare the diagnostic performance of the these three clinical risk scores and POC-troponin.MethodsPrespecified analysis from a prospective, multicentre, cohort study in patients with suspected NSTE-ACS who were transported to an ED between April 2021 and December 2022 in the Netherlands. Risk stratification is performed by EMS personnel using preHEART, HEART, T-MACS and POC-troponin. The primary end point was the hospital diagnosis of NSTE-ACS. The diagnostic performance was expressed as area under the receiver operating characteristic (AUROC), sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV).ResultsA total of 823 patients were included for external validation of the preHEART score, final hospital diagnosis of NSTE-ACS was made in 29% (n=235). The preHEART score classified 27% as low risk, with a sensitivity of 92.8% (95% CI 88.7 to 95.7) and NPV of 92.3% (95% CI 88.3 to 95.1). The preHEART classified 9% of the patients as high risk, with a specificity of 98.5% (95% CI 97.1 to 99.3) and PPV of 87.7% (95% CI 78.3 to 93.4). Data for comparing clinical risk scores and POC-troponin were available in 316 patients. No difference was found between the preHEART score and HEART score (AUROC 0.83 (95% CI 0.78 to 0.87) vs AUROC 0.80 (95% CI 0.74 to 0.85), p=0.19), and both were superior compared with T-MACS (AUROC 0.72 (95% CI 0.66 to 0.79), p≤0.001 and p=0.03, respectively) and POC-troponin measurement alone (AUROC 0.71 (95% CI 0.64 to 0.78), p<0.001 and p=0.01, respectively).ConclusionOn external validation, the preHEART demonstrates good overall diagnostic performance as a prehospital risk stratification tool. Both the preHEART and HEART scores have better overall diagnostic performance compared with T-MACS and sole POC-troponin measurement. These data support the implementation of clinical risk scores in prehospital clinical pathways.Trial registration numberNCT05243485.

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Prehospital triage of patients with suspected non-ST-segment elevation acute coronary syndrome: Rationale and design of the TRIAGE-ACS study

Cited by 4 publications

References 16 publications

Direct admission versus interhospital transfer for revascularisation in non‐ST‐segment elevation myocardial infarction

Direct admission versus interhospital transfer for revascularisation in non‐ST‐segment elevation myocardial infarction

Prehospital risk assessment and direct transfer to a percutaneous coronary intervention centre in suspected acute coronary syndrome

External validation of the preHEART score and comparison with current clinical risk scores for prehospital risk assessment in patients with suspected NSTE-ACS

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