To determine whether risk stratification in the out-of-hospital setting could identify patients with chest pain who are at low and high risk to avoid admission or aid direct transfer to cardiac centers.Methods: Paramedics prospectively enrolled patients with suspected acute coronary syndrome without diagnostic ST-segment elevation on the ECG. The History, ECG, Age and Risk Factors (HEAR) score was recorded contemporaneously, and out-of-hospital samples were obtained to measure cardiac Troponin I (cTnI) level on a point-of-care device, to allow calculation of the History, ECG, Age, Risk Factors, and Troponin (HEART) score. HEAR and HEART scores less than or equal to 3 and greater than or equal to 7 were defined as low and high risk for major adverse cardiac events at 30 days.Results: Of 1,054 patients (64 years [SD 15 years]; 42% women), 284 (27%) experienced a major adverse cardiac event at 30 days. The HEAR score was calculated in all patients, with point-of-care cTnI testing available in 357 (34%). A HEAR score less than or equal to 3 identified 32% of patients (334/1,054) as low risk, with a sensitivity of 84.9% (95% confidence interval [CI] 80.7% to 89%), whereas a score greater than or equal to 7 identified just 3% of patients (30/1,054) as high risk, with a specificity of 98.7% (95% CI 97.9% to 99.5%). A point-of-care HEART score less than or equal to 3 identified a similar proportion as low risk (30%), with a sensitivity of 87.0% (95% CI 80.7% to 93.4%), whereas a score greater than or equal to 7 identified 14% as high risk, with a specificity of 94.8% (95% CI 92.0% to 97.5%). Conclusion:Paramedics can use the HEAR score to discriminate risk, but even when used in combination with out-of-hospital point-of-care cTnI testing, the HEART score does not safely rule out major adverse cardiac events, and only a small proportion of patients are identified as high risk. [
IntroductionThe History, Electrocardiogram (ECG), Age, Risk Factors and Troponin (HEART) score is commonly used to risk stratify patients with possible myocardial infarction as low risk or high risk in the Emergency Department (ED). Whether the HEART score can be used by paramedics to guide care were high-sensitivity cardiac troponin testing available in a prehospital setting is uncertain.MethodsIn a prespecified secondary analysis of a prospective cohort study where paramedics enrolled patients with suspected myocardial infarction, a paramedic Heart, ECG, Age, Risk Factors (HEAR) score was recorded contemporaneously, and a prehospital blood sample was obtained for subsequent cardiac troponin testing. HEART and modified HEART scores were derived using laboratory contemporary and high-sensitivity cardiac troponin I assays. HEART and modified HEART scores of ≤3 and ≥7 were applied to define low-risk and high-risk patients, and performance was evaluated for an outcome of major adverse cardiac events (MACEs) at 30 days.ResultsBetween November 2014 and April 2018, 1054 patients were recruited, of whom 960 (mean 64 (SD 15) years, 42% women) were eligible for analysis and 255 (26%) experienced a MACE at 30 days. A HEART score of ≤3 identified 279 (29%) as low risk with a negative predictive value of 93.5% (95% CI 90.0% to 95.9%) for the contemporary assay and 91.4% (95% CI 87.5% to 94.2%) for the high-sensitivity assay. A modified HEART score of ≤3 using the limit of detection of the high-sensitivity assay identified 194 (20%) patients as low risk with a negative predictive value of 95.9% (95% CI 92.1% to 97.9%). A HEART score of ≥7 using either assay gave a lower positive predictive value than using the upper reference limit of either cardiac troponin assay alone.ConclusionsA HEART score derived by paramedics in the prehospital setting, even when modified to harness the precision of a high-sensitivity assay, does not allow safe rule-out of myocardial infarction or enhanced rule-in compared with cardiac troponin testing alone.
BackgroundCardiac sounding chest pain represents about 5% of all Emergency Department (ED) attendances in the United Kingdom (UK), often via 999 ambulance.Much work has focused on the rapid distinction of the 1 in 5 patients without ST elevation on ECG, who are suffering from a non ST elevation myocardial infarction (NSTEMI). Pre-hospital translation of such work may allow improved access to specialist treatment for patients with NSTEMI and also identify a low risk population suitable for management without immediate ambulance transfer to hospital.The objective was to determine the accuracy of a wholly paramedic calculated pre-hospital HEART score to predict a 30-day Major Adverse Cardiac Event (MACE). The potential implications of pre-specified low-risk and high-risk cut offs were also to be determined.Method and resultsProspective diagnostic accuracy study in Northeast Scotland (UK) on adult (>18 yr) patients with cardiac sounding chest pain, attended by a paramedic ambulance and who had no ST elevation on initial ECG.A real time paramedic HEAR score was calculated and blood drawn for analysis with a POC cTn assay and later with both laboratory based contemporary and high-sensitivity cTn assays. Normal care then ensued and patients were followed up to 30 days for development of MACE.ConclusionsBetween Nov 2014 and April 2018, 1275 patients agreed to participate in the ambulance and 1056 later gave informed consent with 1054 completing 30 day follow up.358 patients had complete Paramedic HEART scores with all 3 assays and 969 patients with the 2 lab based assays (figure 1)Abstract 013 Figure 1Patient flow diagramSensitivities and specificities (95% CI) for the HEART scores vs MACE will be calculated and ROC curves generated. Diagnostic properties at different score cut-offs will be presented and analysis of the impact of the different cTnI assays presented.Apologies: Independent AMI adjudication due to complete next week, so no full results yet.
BackgroundRecent analysis shows a higher risk of death after Out of Hospital Cardiac Arrest (OHCA) for patients who lived in rural areas of UK in casemix adjusted comparison with urban areas. Sandpiper Wildcat is an action research project aiming to increase survival rates through the implementation of a novel network of trained responders in rural Grampian.MethodsAfter using historic data to identify 50 locations with poor response times but significant numbers of OHCA we established teams of trained volunteer responders equipped with automatic external defibrillators (AED 3, Zoll) and Vehicle Locator Systems. Responders were trained and made available for dispatch to OHCA by ambulance control. In addition to real time CPR quality feedback the AED 3 also records ECG, compression metrics and audio of the incident for analysis and debrief.ResultsAround 500 responders were successfully trained and deployed in 53 rural locations during the first 6 months. They were mobilised to 109 OHCA, arriving on scene an average of 7 min (−15 to 48 mins) before Scottish ambulance service resources. Analysis of metrics from defibrillator downloads showed high quality resuscitation. In addition there were many reports of significant ‘added value’ to patients, families and Scottish Ambulance Service staff as a result of Sandpiper Wildcat responders’ attendance. Responders replied overwhelmingly positively to debrief questions ‘did you feel of value at scene’ and ‘do you feel you made a difference’, all indicated that they would be willing to respond again.ConclusionsSandpiper Wildcat project has reduced the response time to OHCA in rural Grampian and increased the number of responders at each OHCA. Responders have delivered high quality BLS and provided assistance to SAS personnel. Further analysis will examine the spread and sustainability of this approach in rural UK and the longer term impact on clinical outcomes.
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