Feasibility of pre-hospital chest pain triage at home or in the ambulance by paramedics using the HEART score based upon a single high-sensitive troponin T analysis

Abstract

Purpose: Triage of patients with chest pain after an Emergency Medical System (EMS) call normally occurs in the hospital emergency room (ER). It has been shown that the HEART-score offers a simple and quick risk-stratifying tool in these patients. Additionally the high-sensitive Troponin T (hs-cTnT) provides a greater diagnostic accuracy and detection of Acute Myocardial Infarction (AMI) compared to the fourth generation TnT. This study investigates whether pre-hospital chest pain triage is feasible, in terms of ruling out AMI already in the ambulance by paramedics using a single hs-TnT measurement in combination with the HEART score. Methods: Patients with acute onset chest pain (with the exclusion of STEMI) who called the EMS, from June -to November 2012 were prospectively evaluated at First Medical Contact (FMC), often at home, by ambulance paramedics including hs-TnT assessment. All patients were then transported immediately to the ER and managed by emergency physicians without knowledge of the HEART score as assessed by the ambulance crew at FMC. Follow-up was performed at 30 days in terms of MACE. Discharge diagnoses were evaluated in case AMI was ruled out. Results: A total of 207 patients were included. The hs-cTnT values was negative (< 0.014 ng/mL) in 123 patients (59%) and the HEART score was 3 or less in 42 patients (34%), as shown in the table. None of the patients with a HEART score of 3 or less had an AMI. The discharge diagnoses of patients with a HEART score of 3 or less were benign, non-cardiac chest pain in 39 patients (93%), a suspicion of supraventicular arrythmia in 2 patients (3.1%) and a suspected biliary colic in 1 patient. View this table: Conclusion: A large number of patients (34%) with symptoms suspicious of AMI who were presented to the EMS system could be identified as being low risk already in the ambulance. This pre-hospital triage provides an excellent tool in identifying both low- and high-risk patients and might help in optimizing logistics and cost-effectiveness for patients with chest pain before hospital admission.