Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study

Dongen, Dominique N van; Tolsma, Rudolf T; Fokkert, Marion J; Badings, Erik A; Sluis, Aize van der; Slingerland, Robbert J.; Hof, Arnoud W J van ‘t; Ottervanger, Jan Paul

doi:10.1177/2048872618813846

Cited by 40 publications

(45 citation statements)

References 33 publications

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“…Recent studies have shown the safety of identifying low-risk chest pain patients in a prehospital environment 22 23. The FAMOUS triage study group has demonstrated that identifying low-risk chest pain patients by ambulance staff using a modified HEART score is feasible and safe when using a high-sensitive troponin T measurement in the hospital laboratory 22.…”

Section: Discussionmentioning

confidence: 99%

“…They have also shown that using a POC troponin T measurement to turn the HEAR score into the HEART score in the prehospital setting has important additional predictive value 31. Furthermore, they have shown that in patients suspected of NSTE-ACS, HEART score assessment using a POC troponin T measurement by ambulance paramedics is accurate in identifying low-risk patients 23…”

Section: Discussionmentioning

confidence: 99%

“…The FAMOUS triage study group has demonstrated that HEART score assessment by ambulance paramedics is feasible and safe 22. Moreover, ambulance paramedics can adequately assess a complete HEART score, using a point-of-care (POC) troponin T measurement 23. Thus, prehospital triage of patients suspected of a NSTE-ACS is possible.…”

Section: Introductionmentioning

confidence: 99%

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Acute rule-out of non–ST-segment elevation acute coronary syndrome in the (pre)hospital setting by HEART score assessment and a single point-of-care troponin: rationale and design of the ARTICA randomised trial

et al. 2020

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IntroductionBecause of the lack of prehospital protocols to rule out a non-ST-segment elevation acute coronary syndrome (NSTE-ACS), patients with chest pain are often transferred to the emergency department (ED) for thorough evaluation. However, in low-risk patients, an ACS is rarely found, resulting in unnecessary healthcare consumption. Using the HEART (History, ECG, Age, Risk factors and Troponin) score, low-risk patients are easily identified. When a point-of-care (POC) troponin measurement is included in the HEART score, an ACS can adequately be ruled out in low-risk patients in the prehospital setting. However, it remains unclear whether a prehospital rule-out strategy using the HEART score and a POC troponin measurement in patients with suspected NSTE-ACS is cost-effective.Methods and analysisThe ARTICA trial is a randomised trial in which the primary objective is to investigate the cost-effectiveness after 30 days of an early rule-out strategy for low-risk patients suspected of a NSTE-ACS, using a modified HEART score including a POC troponin T measurement. Patients are included by ambulance paramedics and 1:1 randomised for (1) presentation at the ED (control group) or (2) POC troponin T measurement (intervention group) and transfer of the care to the general practitioner in case of a low troponin T value. In total, 866 patients will be included. Follow-up will be performed after 30 days, 6 months and 12 months.Ethics and disseminationThis trial has been accepted by the Medical Research Ethics Committee region Arnhem-Nijmegen. The results of this trial will be disseminated in one main paper and in additional papers with subgroup analyses.Trial registration numberNetherlands Trial Register (NL7148).

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Acute rule-out of non–ST-segment elevation acute coronary syndrome in the (pre)hospital setting by HEART score assessment and a single point-of-care troponin: rationale and design of the ARTICA randomised trial

et al. 2020

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“…The primary outcome was the occurrence of major adverse cardiac events within 30 days. 26 In addition, van Dongen, et al 27,28 have evaluated both the HEART and HEAR scores in the prehospital setting. The primary outcome for both papers was major adverse cardiac events within 35 days.…”

Section: Discussionmentioning

confidence: 99%

Diagnostic Performance of Prehospital Point-of-Care Troponin Tests to Rule Out Acute Myocardial Infarction: A Systematic Review

Alghamdi

Alotaibi

Alharbi

et al. 2020

Prehosp. Disaster med.

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Abstract Introduction: Chest pain is one of the most common reasons for 999 calls and transfers to the emergency department (ED). In these patients, acute myocardial infarction (AMI) is often the diagnosis that clinicians are seeking to exclude. However, only a minority of those patients have AMI, causing a substantial financial burden to health services. Cardiac troponin (cTn) is the reference standard biomarker for the diagnosis of AMI. Several commercially available point-of-care (POC) cTn assays are portable and could feasibly be used in an ambulance. The aim of this paper is to systematically review existing evidence for the use of POC cTn assays in the prehospital setting to rule out AMI. Methods: A systematic search was conducted on EMBASE, MEDLINE, and CINAHL Plus databases, reference lists, and relevant grey literature, including combinations of the relevant terms. Papers published in English language since the year 2000 were eligible for inclusion. A narrative synthesis of the evidence was then undertaken. Results: The initial search and cross-referencing revealed a total of 350 papers, of which 243 were excluded. Seven papers were included in the systematic literature review. Conclusion: Current evidence does not support the use of POC troponin assays to exclude AMI due to issues with diagnostic accuracy and insufficient high-quality evidence.

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“…1 2 Due to limited diagnostic tests, the AMI diagnosis is challenging in the prehospital emergency setting, [3][4][5] and the value of prehospital risk stratification with point-ofcare troponins with or without risk assessment scores has received increased attention during the last decade. [6][7][8] Still, there is no prehospital strategy that safely excludes AMI outside of hospitals. 5 8 9 The introduction of high-sensitivity assays for cardiac troponins opened for rapid diagnostic pathways in hospitals, [10][11][12] and the diagnostic utility of the 2015 European Society of Cardiology (ESC) 0/1-hour algorithm for high-sensitivity cardiac troponin T (hs-cTnT) 2 has been confirmed in large validation studies from hospital emergency departments (EDs).…”

Section: Introductionmentioning

confidence: 99%

Pre-hospital One-Hour Troponin in a Low-Prevalence Population of Acute Coronary Syndrome: OUT-ACS study

et al. 2020

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ObjectiveThe European Society of Cardiology 0/1-hour algorithm for high-sensitivity cardiac troponin T (hs-cTnT) has demonstrated high rule-out safety in large hospital validation cohorts. We aimed to validate the algorithm in a primary care setting, where patients have a lower pretest probability for acute coronary syndrome.MethodsThis prospective, observational, diagnostic study included patients with acute non-specific chest pain admitted to a primary care emergency clinic in Oslo, Norway, from November 2016 to October 2018. hs-cTnT was measured after 0, 1 and 4 hours. The primary outcome measure was the diagnostic performance of the 0/1-hour algorithm, the 90-day incidence of AMI or all-cause death the secondary.ResultsAmong 1711 included patients, 61 (3.6%) were diagnosed with AMI. By applying the algorithm, 1311 (76.6%) patients were assigned to the rule-out group. The negative predictive value was 99.9% (95% CI 99.5% to 100.0%), the sensitivity and specificity 98.4% (91.2–100.0) and 79.4% (77.4–81.3), respectively. Sixty-six (3.9%) patients were triaged towards rule-in, where 45 were diagnosed with AMI. The corresponding positive predictive value was 68.2% (58.3–76.7), sensitivity 73.8% (60.9–84.2), and specificity 98.7% (98.1–99.2). Among 334 (19.5%) patients assigned to the observation group in need of further tests, 15 patients had an AMI. The following 90 days, five new patients experienced an AMI and nine patients died, with a low incidence in the rule-out group (0.3%).ConclusionThe 0/1-hour algorithm for hs-cTnT seems safe, efficient and applicable for an accelerated assessment of patients with non-specific chest pain in a primary care emergency setting.Trial registration numberNCT02983123.

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Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study

Cited by 40 publications

References 33 publications

Acute rule-out of non–ST-segment elevation acute coronary syndrome in the (pre)hospital setting by HEART score assessment and a single point-of-care troponin: rationale and design of the ARTICA randomised trial

Acute rule-out of non–ST-segment elevation acute coronary syndrome in the (pre)hospital setting by HEART score assessment and a single point-of-care troponin: rationale and design of the ARTICA randomised trial

Diagnostic Performance of Prehospital Point-of-Care Troponin Tests to Rule Out Acute Myocardial Infarction: A Systematic Review

Pre-hospital One-Hour Troponin in a Low-Prevalence Population of Acute Coronary Syndrome: OUT-ACS study

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