Could High-Sensitivity Cardiac Troponin Testing Rule Out Acute Myocardial Infarction in the Prehospital Setting?

Cooper, Jamie G; Ferguson, James; Donaldson, Lorna A.; Black, Kim M.M.; Horrill, Judith L.; Davidson, Elaine M.; Scott, Neil; Fujisawa, Takeshi; Chapman, Andrew; Mills, Nicholas L

doi:10.1016/j.jacc.2021.10.004

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“…High-sensitivity cardiac troponin assays permit the quantification of troponin within the normal reference range and, at the assay limit of detection (LoD)15 or optimised thresholds,3 permit the safe rule-out of myocardial infarction at presentation in the ED. Secondary analysis of a large prehospital cohort highlighted the potential for high-sensitivity troponin to improve risk stratification in this environment,16 and modification of the HEART score using lower cardiac troponin thresholds may improve rule-out performance 9. Whether this approach could be applied in the prehospital setting remains uncertain.…”

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confidence: 99%

Performance of a prehospital HEART score in patients with possible myocardial infarction: a prospective evaluation

Cooper

Ferguson

Donaldson³

et al. 2023

Emerg Med J

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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.

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