Prehospital use of a modified HEART Pathway and point-of-care troponin to predict cardiovascular events

Stopyra, Jason P.; Snavely, Anna C.; Smith, Lane M.; Harris, Roger; Nelson, R. Darrell; Winslow, James E.; Alson, Roy L.; Pomper, Gregory J.; Riley, Robert F.; Ashburn, Nicklaus P.; Hendley, Nella; Gaddy, Jeremiah; Woodrum, Tyler; Fornage, Louis; Conner, David A.; Alvarez, Manrique; Pflum, Adam; Koehler, Lauren E.; Miller, Chadwick D.; Mahler, Simon A.

doi:10.1371/journal.pone.0239460

Cited by 15 publications

(15 citation statements)

References 33 publications

(37 reference statements)

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“…Currently, several studies, demonstrated that in patients with suspected NSTE-ACS pre-hospital risk assessment is feasible, and that outcome is comparable with risk assessments performed in the hospital. 30 , 31 Although previous studies showed promising results, structured pre-hospital risk assessment is not yet implemented in routine daily practice.…”

Section: Discussionmentioning

confidence: 99%

Referral decisions based on a pre-hospital HEART score in suspected non-ST-elevation acute coronary syndrome: final results of the FamouS Triage study

Tolsma¹,

Fokkert

Dongen

et al. 2021

European Heart Journal. Acute Cardiovascular Care

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Aims Although pre-hospital risk stratification of patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) by ambulance paramedics is feasible, it has not been investigated in daily practice whether referral decisions based on this risk stratification is safe and does not increase major adverse cardiac events (MACE). In Phase III of the FamouS Triage study, it was investigated whether referral decisions by ambulance paramedics based on a pre-hospital HEART score, is non-inferior to routine management. Methods and results FamouS Triage Phase III is a non-inferiority study, comparing the occurrence of MACE before (Phase II) and after (Phase III) implementation of referral decisions based on a pre-hospital HEART score. In Phase II, all patients were risk-stratified and referred to the hospital; in Phase III, low-risk patients (HEART score ≤ 3) were not referred. Primary endpoint was MACE (acute coronary syndrome, revascularization, or death) within 45 days. A total of 1236 patients were included. Mean age was 63 years, 43% were female, 700 patients were included in the second phase and 536 in the third phase in which 149 low-risk patients (28%) were not transferred to the hospital. Occurrence of 45 days MACE was 16.6% in Phase II and 15.7% in Phase III (P = 0.67). Percentage MACE in low-risk patients was 2.9% in Phase II and 1.3% in Phase III. After adjustments for differences in baseline variables, the hazard ratio of 45 days MACE in Phase III was 0.88 (95% confidence interval 0.63–1.25) as compared to Phase II. Conclusion Pre-hospital risk stratification of patients with suspected NSTE-ACS, avoiding hospitalization of a substantial number of low-risk patients, seems feasible and non-inferior to transferring all patients to the hospital.

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Section: Discussionmentioning

confidence: 99%

Referral decisions based on a pre-hospital HEART score in suspected non-ST-elevation acute coronary syndrome: final results of the FamouS Triage study

Tolsma¹,

Fokkert

Dongen

et al. 2021

European Heart Journal. Acute Cardiovascular Care

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“…com/EJEM/A333). The high risk of bias was found with respect to flow and timing, due to considering patients with incomplete follow-up as free of MACE [10,41]. We found all studies at low concern regarding applicability.…”

Section: Description Of Included Studiesmentioning

confidence: 77%

The performance of HEAR score for identification of low-risk chest pain: a systematic review and meta-analysis

Rad

Pirmoradi

Doosti-Irani

et al. 2022

European Journal of Emergency Medicine

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Chest pain is one of the most common presentations to the emergency department (ED) and HEART score (history, ECG, age, risk factors, and cardiac troponin) is recommended for risk stratification. It has been proposed that the sum of four items with no troponin (HEAR score) below 2 can be used safely to lower testing and reduce length of stay. To assess the performance of the HEAR score in hospital and prehospital settings, we performed a systematic review and meta-analysis. English studies on the performance of the HEAR score in patients with acute chest pain were included. They were excluded if data are inaccessible. MEDLINE, Embase, Evidence-Based Medicine Reviews, Scopus, and web of science were searched from 1946 to July 2021. The quality of studies was assessed using Quality Assessment of Diagnostic Accuracy Studies version 2. Acute coronary syndrome or major adverse cardiac events prediction were outcomes of interest. The performance indices with 95% confidence intervals (CIs) were extracted. Inverse variance and the random-effects model were used to report the results. Of the 692 articles on the HEAR score, 10 studies were included in the analysis with 33 843 patients. Studies were at low to moderate risk of bias. Three studies were in prehospital and three were retrospective. The pooling of data on the HEAR score showed that the sensitivity at the HEAR<2, <3, and <4 cutoffs in the ED were 99.03% (95% CI, 98.29–99.77), 97.54% (95% CI, 94.50–100), and 91.80% (95% CI, 84.62–98.98), respectively. The negative predictive values (NPVs) for the above cutoffs were 99.84% (95% CI, 99.72–99.95), 99.75% (95% CI, 99.65–99.85), and 99.57% (95% CI, 99.11–100), respectively. Of note, for the HEAR<2, negative likelihood ratio was 0.07 (95% CI, 0.02–0.12). In the prehospital, at the HEAR<4 cutoff, the pooled sensitivity and NPV were 85.01% (95% CI, 80.56–89.47) and 91.48% (95% CI, 87.10–95.87), respectively. This study showed that in the ED, the HEAR score<2 can be used for an early discharge strategy. Currently, this score cannot be recommended in prehospital setting. Prospero (CRD42021273710).

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“…An example of such scores are the preHEART and the modi ed HEART pathway which use the patients' history, ECG, risk factors and a Point-of-Care (POC) Troponin. (15,16) These scores provide paramedics with the opportunity to make a strati cation of likelihood for patients with undifferentiated chest pain for having a NSTEMI. The likelihood ratio of combined risk scores for risk strati cation in suspected NSTEMI patients are currently better then standalone history, ECG and, POC-Troponin alone.…”

Section: Pre-hospital Triagementioning

confidence: 99%

Direct Admission Versus Interhospital Transfer for revascularisation in non-ST-Segment Elevation Myocardial Infarction

Steenbergen

Demandt

Schulz

et al. 2022

Preprint

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Objective We aim to compare quality parameters, costs and clinical outcomes of NSTEMI patients stratified by centre of first presentation and revascularisation strategy. Methods Hospital claim data on patients admitted with a NSTEMI between 2017 and 2019 from one of the largest health insurers in the Netherlands were used for this study. Included patients were stratified by revascularisation strategy (PCI, CABG or no revascularisation [noRevasc]) and subdivided by centre of presentation per treatment. The primary outcomes were the following quality measures: duration between admission and revascularisation, length of hospital stay and number of intracoronary procedures. Total costs (accumulation of costs for hospital claims and inter-hospital ambulance rides) and clinical outcomes at 30 days (MACE: all-cause mortality, recurrent myocardial infarction and cardiac readmission) were used as secondary outcomes. Results A total of 9641 NSTEMI events (9167 unique patients) were analysed for which PCI was performed during admission in 4448 cases, CABG in 816 cases and no revascularisation was performed in 4377 cases. Direct presentation at an intervention centre occurred in 59%, 55% and 60% of cases, respectively. For PCI, direct presentation at an intervention centre yielded shorter time to revascularisation, shorter hospitalisation and less intracoronary procedures per patient. For CABG, time to revascularisation and hospitalisation were shorter. Total costs were significantly lower in case of direct presentation in an intervention centre for all treatment groups while MACE was similar. Conclusion Direct admission of NSTEMI patients to an intervention centre might yield improvement potential for current NSTEMI care.

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Prehospital use of a modified HEART Pathway and point-of-care troponin to predict cardiovascular events

Cited by 15 publications

References 33 publications

Referral decisions based on a pre-hospital HEART score in suspected non-ST-elevation acute coronary syndrome: final results of the FamouS Triage study

Referral decisions based on a pre-hospital HEART score in suspected non-ST-elevation acute coronary syndrome: final results of the FamouS Triage study

The performance of HEAR score for identification of low-risk chest pain: a systematic review and meta-analysis

Direct Admission Versus Interhospital Transfer for revascularisation in non-ST-Segment Elevation Myocardial Infarction

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