The Ambulance Cardiac Chest Pain Evaluation in Scotland Study (ACCESS): A Prospective Cohort Study

Abstract

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. [

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

“…In this systematic review, 33 843 patients were included from 10 studies [9,10,33–40]. Five studies were conducted in Europe [9,33,34,38,40], one in Asia [37], and the rest in North America [10,35,36,39].…”

“…In this systematic review, 33 843 patients were included from 10 studies [9,10,33–40]. Five studies were conducted in Europe [9,33,34,38,40], one in Asia [37], and the rest in North America [10,35,36,39]. Seven studies were conducted in the EDs [9,10,34–38] and three studies were in the prehospital [33,39,40].…”

Development and validation of a comprehensive early risk prediction model for patients with undifferentiated acute chest pain

“…This study aimed to assess a measure of all-inclusive early risk among chest pain cohorts. Current literature assessing early risk among chest pain focuses on the risk of myocardial infarction (MI), generally at 30 days [9] , [10] , [11] , [13] , [14] , [15] . Therefore, the composite primary endpoint included 30-day MI, in addition to admission to hospital at the index presentation and 30-day all-cause mortality, with the following specific criteria: (1) admission to hospital (excluding admission to emergency short stay assessment areas for < 24 h) with any discharge diagnosis except for non-specific pain (including serious diagnoses such as myocardial infarction, pulmonary emboli, heart failure, pneumothorax, pneumonia and acute aortic pathologies); (2) myocardial infarction, defined as either an ST-elevation or non-ST elevation myocardial infarction within 30 days of emergency or hospital discharge; (3) all-cause mortality within 30 days of EMS attendance.…”

Journal Update

“…The Ambulance Cardiac Chest Pain Evaluation in Scotland Study (ACCESS) was a prospective diagnostic accuracy study that included patients with chest pain who had called for an emergency ambulance. 4 Paramedics collected data and took venous blood samples, which were analysed using the Samsung LABGEO POCT for conventional cardiac troponin. The authors evaluated the accuracy of the HEART and HEAR scores (HEART without troponin testing).…”