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

Jesse P A Demandt, Jo M Zelis, Arjan Koks, Geert H J M Smits, Pim van der Harst, Pim A L Tonino, Lukas R C Dekker, Marcel van Het Veer, Pieter-Jan Vlaar, Jesse P A Demandt, Jo M Zelis, Arjan Koks, Geert H J M Smits, Pim van der Harst, Pim A L Tonino, Lukas R C Dekker, Marcel van Het Veer, Pieter-Jan Vlaar

Abstract

Objective: To 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).

Methods: Systematic 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 measures: Sensitivity, specificity and likelihood ratio of findings for risk stratification in patients suspected of NSTE-ACS.

Results: In 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)).

Discussion: Important 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.

Funding: This study is funded by ZonMw, the Dutch Organisation for Health Research and Development.

Trial registration number: This meta-analysis was published for registration in PROSPERO prior to starting (CRD York, CRD42021254122).

Keywords: cardiology; coronary heart disease; myocardial infarction; primary care.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Graphical abstract. It shows the indicative positive and negative likelihood ratio (LR) for each element and how it compares to its predictive value. POC, point-of-care.

References

    1. Hoorweg BB, Willemsen RT, Cleef LE, et al. . Frequency of chest pain in primary care, diagnostic tests performed and final diagnoses. Heart 2017;103:1727–32. 10.1136/heartjnl-2016-310905
    1. Pedersen CK, Stengaard C, Friesgaard K, et al. . Chest pain in the ambulance; prevalence, causes and outcome - a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2019;27:84. 10.1186/s13049-019-0659-6
    1. Thang ND, Karlson BW, Bergman B, et al. . Characteristics of and outcome for patients with chest pain in relation to transport by the emergency medical services in a 20-year perspective. Am J Emerg Med 2012;30:1788–95. 10.1016/j.ajem.2012.02.014
    1. Wibring K, Lingman M, Herlitz J, et al. . Prehospital stratification in acute chest pain patient into high risk and low risk by emergency medical service: a prospective cohort study. BMJ Open 2021;11:e044938. 10.1136/bmjopen-2020-044938
    1. Backus BE, Six AJ, Kelder JC, et al. . A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol 2013;168:2153–8. 10.1016/j.ijcard.2013.01.255
    1. Antman EM, Cohen M, Bernink PJ, et al. . The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA 2000;284:835–42. 10.1001/jama.284.7.835
    1. Harskamp R, van Peet P, Bont J, et al. . The conundrum of acute chest pain in general practice: a nationwide survey in The Netherlands. BJGP Open 2018;2:bjgpopen18X101619. 10.3399/bjgpopen18X101619
    1. Collet JP, Thiele H, Barbato E. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Rev Esp Cardiol 20202021;74:544.
    1. Bainey KR, Gafni A, Rao-Melacini P, et al. . The cost implications of an early versus delayed invasive strategy in acute coronary syndromes: the TIMACS study. J Med Econ 2014;17:415–22. 10.3111/13696998.2014.911184
    1. Nieuwets A, Poldervaart JM, Reitsma JB, et al. . Medical consumption compared for TIMI and HEART score in chest pain patients at the emergency department: a retrospective cost analysis. BMJ Open 2016;6:e010694. 10.1136/bmjopen-2015-010694
    1. de Koning E, Biersteker TE, Beeres S, et al. . Prehospital triage of patients with acute cardiac complaints: study protocol of HART-c, a multicentre prospective study. BMJ Open 2021;11:e041553. 10.1136/bmjopen-2020-041553
    1. Goodacre S, Cross E, Arnold J, et al. . The health care burden of acute chest pain. Heart 2005;91:229–30. 10.1136/hrt.2003.027599
    1. Kienbacher CL, Fuhrmann V, van Tulder R, et al. . Impact of more conservative European Society of Cardiology guidelines on the management of patients with acute chest pain. Int J Clin Pract 2021;75:e14133. 10.1111/ijcp.14133
    1. Boubaker H, Grissa MH, Beltaief K, et al. . A new score for the diagnosis of acute coronary syndrome in acute chest pain with non-diagnostic ECG and normal troponin. Emerg Med J 2015;32:764–8. 10.1136/emermed-2013-203151
    1. Stopyra JP, Snavely AC, Smith LM, et al. . Prehospital use of a modified HEART pathway and point-of-care troponin to predict cardiovascular events. PLoS One 2020;15:e0239460. 10.1371/journal.pone.0239460
    1. van Dongen DN, Fokkert MJ, Tolsma RT, et al. . Accuracy of pre-hospital HEART score risk classification using point of care versus high sensitive troponin in suspected NSTE-ACS. Am J Emerg Med 2020;38:1616–20. 10.1016/j.ajem.2019.158448
    1. Rasmussen MB, Stengaard C, Sørensen JT, et al. . Predictive value of routine point-of-care cardiac troponin T measurement for prehospital diagnosis and risk-stratification in patients with suspected acute myocardial infarction. Eur Heart J Acute Cardiovasc Care 2019;8:299–308. 10.1177/2048872617745893
    1. Whiting PF, Weswood ME, Rutjes AWS, et al. . Evaluation of QUADAS, a tool for the quality assessment of diagnostic accuracy studies. BMC Med Res Methodol 2006;6:9. 10.1186/1471-2288-6-9
    1. McGee S. Simplifying likelihood ratios. J Gen Intern Med 2002;17:647–50. 10.1046/j.1525-1497.2002.10750.x
    1. Honest H, Khan KS. Reporting of measures of accuracy in systematic reviews of diagnostic literature. BMC Health Serv Res 2002;2:4. 10.1186/1472-6963-2-4
    1. Grimes DA, Schulz KF. Refining clinical diagnosis with likelihood ratios. Lancet 2005;365:1500–5. 10.1016/S0140-6736(05)66422-7
    1. Shim SR, Kim S-J, Lee J. Diagnostic test accuracy: application and practice using R software. Epidemiol Health 2019;41:e2019007. 10.4178/epih.e2019007
    1. Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med 2002;21:1539–58. 10.1002/sim.1186
    1. Anroedh SS, Kardys I, Akkerhuis KM, et al. . e-Transmission of ECGs for expert consultation results in improved triage and treatment of patients with acute ischaemic chest pain by ambulance paramedics. Neth Heart J 2018;26:562–71. 10.1007/s12471-018-1187-0
    1. Svensson L, Isaksson L, Axelsson C, et al. . Predictors of myocardial damage prior to hospital admission among patients with acute chest pain or other symptoms raising a suspicion of acute coronary syndrome. Coron Artery Dis 2003;14:225–31. 10.1097/01.mca.0000063503.13456.0d
    1. Bruins Slot MHE, Rutten FH, van der Heijden GJMG, et al. . Diagnostic value of a heart-type fatty acid-binding protein (H-FABP) bedside test in suspected acute coronary syndrome in primary care. Int J Cardiol 2013;168:1485–9. 10.1016/j.ijcard.2012.12.050
    1. Andersson PO, Karlsson J-E, Landberg E, et al. . Consequences of high-sensitivity troponin T testing applied in a primary care population with chest pain compared with a commercially available point-of-care troponin T analysis: an observational prospective study. BMC Res Notes 2015;8:210. 10.1186/s13104-015-1174-0
    1. Willemsen RT, Winkens B, Kietselaer BL, et al. . Evaluating possible acute coronary syndrome in primary care: the value of signs, symptoms, and plasma heart-type fatty acid-binding protein (H-FABP). A diagnostic study. BJGP Open 2019;3:bjgpopen19X101652. 10.3399/bjgpopen19X101652
    1. Nilsson S, Andersson PO, Borgquist L, et al. . Point-of-care troponin T testing in the management of patients with chest pain in the Swedish primary care. Int J Family Med 2013;2013:53209310.1155/2013/532093
    1. Stengaard C, Sørensen JT, Ladefoged SA, et al. . Quantitative point-of-care troponin T measurement for diagnosis and prognosis in patients with a suspected acute myocardial infarction. Am J Cardiol 2013;112:1361–6. 10.1016/j.amjcard.2013.06.026
    1. Ishak M, Ali D, Fokkert MJ, et al. . Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (famous triage): ruling out a myocardial infarction at home with the modified HEART score. Eur Heart J Acute Cardiovasc Care 2018;7:102–10. 10.1177/2048872616687116
    1. van Dongen DN, Tolsma RT, Fokkert MJ, et al. . Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: a prospective observational study. Eur Heart J Acute Cardiovasc Care 2020;9:5–12. 10.1177/2048872618813846
    1. van Dongen DN, Fokkert MJ, Tolsma RT, et al. . Value of prehospital troponin assessment in suspected non-ST-elevation acute coronary syndrome. Am J Cardiol 2018;122:1610–6. 10.1016/j.amjcard.2018.07.037
    1. Schols AMR, Willemsen RTA, Bonten TN, et al. . A nationwide flash-mob study for suspected acute coronary syndrome. Ann Fam Med 2019;17:296–303. 10.1370/afm.2401
    1. Sagel DC, Vlaar PJ, Waardenburg I. Pre-hospital risk stratification in patients with undifferentiated chest pain 2021.
    1. Collet J-P, Thiele H, Barbato E, et al. . 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021;42:1289–367. 10.1093/eurheartj/ehaa575
    1. Boeddinghaus J, Nestelberger T, Koechlin L, et al. . Early diagnosis of myocardial infarction with point-of-care high-sensitivity cardiac troponin I. J Am Coll Cardiol 2020;75:1111–24. 10.1016/j.jacc.2019.12.065
    1. Dekker MS, Mosterd A, van 't Hof AWJ, et al. . Novel biochemical markers in suspected acute coronary syndrome: systematic review and critical appraisal. Heart 2010;96:1001–10. 10.1136/hrt.2009.189886
    1. Lippi G, Mattiuzzi C, Cervellin G. Critical review and meta-analysis on the combination of heart-type fatty acid binding protein (H-FABP) and troponin for early diagnosis of acute myocardial infarction. Clin Biochem 2013;46:26–30. 10.1016/j.clinbiochem.2012.10.016
    1. Bivona G, Agnello L, Bellia C, et al. . Diagnostic and prognostic value of H-FABP in acute coronary syndrome: still evidence to bring. Clin Biochem 2018;58:1–4. 10.1016/j.clinbiochem.2018.04.021
    1. Bruins Slot MHE, van der Heijden GJMG, Stelpstra SD, et al. . Point-of-care tests in suspected acute myocardial infarction: a systematic review. Int J Cardiol 2013;168:5355–62. 10.1016/j.ijcard.2013.08.002
    1. Fanaroff AC, Rymer JA, Goldstein SA, et al. . Does this patient with chest pain have acute coronary syndrome?: the rational clinical examination systematic review. JAMA 2015;314:1955–65. 10.1001/jama.2015.12735
    1. Alghamdi A, Cook E, Carlton E, et al. . PRe-hospital evaluation of sensitive troponin (PRESTO) study: multicentre prospective diagnostic accuracy study protocol. BMJ Open 2019;9:e032834. 10.1136/bmjopen-2019-032834
    1. Aarts GWA, Camaro C, van Geuns R-J, et al. . 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. BMJ Open 2020;10:e034403. 10.1136/bmjopen-2019-034403
    1. van Dongen DN, Tolsma RT, Fokkert MJ, et al. . Referral decisions based on a prehospital HEART score in suspected non-ST-elevation acute coronary syndrome: design of the famous triage 3 study. Future Cardiol 2020;16:217–26. 10.2217/fca-2019-0030
    1. Macaskill P, Gatsonis C, Deeks J, et al. . Chapter 10: analysing and presenting results. In: Cochrane handbook for systematic reviews of diagnostic test accuracy Version 10, 2010.

Source: PubMed

Sponsorer og samarbejdspartnere

Medicinske tilstande

Narkotikainterventioner

3
Abonner