Prehospital risk stratification in patients with chest pain. Issue 11 (9th August 2021)

• Record Type: Journal Article
• Authors: Sagel, Dennis; Vlaar, Pieter Jan; van Roosmalen, Radboud; Waardenburg, Ingmar; Nieuwland, Wybe; Lettinga, Roelof; van Barneveld, Robert; Jorna, Edward; Kijlstra, Roelof; van Well, Carien; Oomen, Antoon; Bartels, Louis; Anthonio, Rutger; Hagens, Vincent; Hofma, Sjoerd; Gu, Youlan; Drenth, Derk; Addink, Ryanne; van Asselt, Thea; van der Meer, Peter; Lipsic, Eric; Juarez Orozco, Luis; van der Harst, Pim
• Is Part Of: Emergency medicine journal. Volume 38:Issue 11(2021)
• Page Start: 814
• Page End: 819
• Publication Date: 2021-08-09
• Subjects: cost effectiveness -- emergency ambulance systems -- effectiveness -- cardiac care -- acute coronary syndrome -- prehospital care; Emergency medicine -- Periodicals; 616.02505
• DOI: 10.1136/emermed-2020-210212
• Languages: English
• ISSNs: 1472-0205

Abstract

Abstract : Objectives: The 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. Methods: In 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. Results: Among 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. Conclusions: The 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.