Prehospital risk assessment in patients suspected of non-ST-segment elevation acute coronary syndrome: a systematic review and meta-analysis

Abstract

ObjectiveTo review, inventory and compare available diagnostic tools and investigate which tool has the best performance for prehospital risk assessment in patients suspected of non-ST-segment elevation acute coronary syndrome (NSTE-ACS).MethodsSystematic review and meta-analysis. Medline and Embase were searched up till 1 April 2021. Prospective studies with patients, suspected of NSTE-ACS, presenting in the primary care setting or by emergency medical services (EMS) were included. The most important exclusion criteria were studies including only patients with ST-elevation myocardial infarction and studies before 1995, the pretroponin era. The primary end point was the final hospital discharge diagnosis of NSTE-ACS or major adverse cardiac events (MACE) within 6 weeks. Risk of bias was evaluated by the Quality Assessment of Diagnostic Accuracy Studies Criteria.Main outcome and measuresSensitivity, specificity and likelihood ratio of findings for risk stratification in patients suspected of NSTE-ACS.ResultsIn total, 15 prospective studies were included; these studies reflected in total 26 083 patients. No specific variables related to symptoms, physical examination or risk factors were useful in risk stratification for NSTE-ACS diagnosis. The most useful electrocardiographic finding was ST-segment depression (LR+3.85 (95% CI 2.58 to 5.76)). Point-of-care troponin was found to be a strong predictor for NSTE-ACS in primary care (LR+14.16 (95% CI 4.28 to 46.90) and EMS setting (LR+6.16 (95% CI 5.02 to 7.57)). Combined risk scores were the best for risk assessment in an NSTE-ACS. From the combined risk scores that can be used immediately in a prehospital setting, the PreHEART score, a validated combined risk score for prehospital use, derived from the HEART score (History, ECG, Age, Risk factors, Troponin), was most useful for risk stratification in patients with NSTE-ACS (LR+8.19 (95% CI 5.47 to 12.26)) and for identifying patients without ACS (LR−0.05 (95% CI 0.02 to 0.15)).DiscussionImportant study limitations were verification bias and heterogeneity between studies. In the prehospital setting, several diagnostic tools have been reported which could improve risk stratification, triage and early treatment in patients suspected for NSTE-ACS. On-site assessment of troponin and combined risk scores derived from the HEART score are strong predictors. These results support further studies to investigate the impact of these new tools on logistics and clinical outcome.FundingThis study is funded by ZonMw, the Dutch Organisation for Health Research and Development.Trial registration numberThis meta-analysis was published for registration in PROSPERO prior to starting (CRD York, CRD42021254122).

Early predictors of severe left main and/or three‐vessel disease in patients with non‐ST‐segment elevation myocardial infarction: A dual‐center retrospective study

“…The conventional 12‐lead ECG is a widely accessible and noninvasive clinical tool. The assessment of ECG parameters plays a crucial role in the initial evaluation of patients with acute coronary syndrome (ACS), while also providing valuable prognostic information (Burak et al., 2019 ; Demandt et al., 2022 ; Karakayali et al., 2023 ; Solà‐Muñoz et al., 2023 ; Wagner et al., 2009 ). Most previous research studies have primarily concentrated on evaluating the clinical significance of ST segment depression in patients diagnosed with ACS (Demandt et al., 2022 ; Solà‐Muñoz et al., 2023 ; Wagner et al., 2009 ).…”

“…The assessment of ECG parameters plays a crucial role in the initial evaluation of patients with acute coronary syndrome (ACS), while also providing valuable prognostic information (Burak et al., 2019 ; Demandt et al., 2022 ; Karakayali et al., 2023 ; Solà‐Muñoz et al., 2023 ; Wagner et al., 2009 ). Most previous research studies have primarily concentrated on evaluating the clinical significance of ST segment depression in patients diagnosed with ACS (Demandt et al., 2022 ; Solà‐Muñoz et al., 2023 ; Wagner et al., 2009 ). However, in patients diagnosed with NSTE‐ACS, the occurrence of ST‐segment elevation in lead aVR was indicated to have a stronger correlation with LM/3VD in comparison to ST‐segment depression in other leads (Kosuge et al., 2009 , 2011 ; Misumida et al., 2016 ).…”

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

“…Previous studies have shown a broad range of incidence of NSTE-ACS as well as various invasive diagnostics in patients presenting with chest pain at the ED. 9 In this population suspected of NSTE-ACS, we estimate that around 30% will undergo invasive diagnostics followed by percutaneous or surgical revascularisation in the majority of them (60-70%). The mean interval until invasive diagnostics and revascularisation is approximately 4 days.…”

“…5 6 The preHEART score is an accurate and validated tool for risk stratification and triage decisions in the prehospital setting. [7][8][9][10] This clinical risk score includes a point-of-care (POC) troponin and allows EMS personnel to stratify patients into low risk or high risk for NSTE-ACS. Recent studies have shown that it is safe and feasible to leave patients at low risk of NSTE-ACS at home or transfer them to a general practitioner in the prehospital setting, leading to reduced emergency department (ED) overcrowding and lower healthcare costs.…”