Abstract
INTRODUCTION: The History, Electrocardiogram (ECG), Age, Risk Factors and Troponin (HEART) score is commonly used to risk stratify patients with possible myocardial infarction as low risk or high risk in the Emergency Department (ED). Whether the HEART score can be used by paramedics to guide care were high-sensitivity cardiac troponin testing available in a prehospital setting is uncertain.
METHODS: In a prespecified secondary analysis of a prospective cohort study where paramedics enrolled patients with suspected myocardial infarction, a paramedic Heart, ECG, Age, Risk Factors (HEAR) score was recorded contemporaneously, and a prehospital blood sample was obtained for subsequent cardiac troponin testing. HEART and modified HEART scores were derived using laboratory contemporary and high-sensitivity cardiac troponin I assays. HEART and modified HEART scores of ≤3 and ≥7 were applied to define low-risk and high-risk patients, and performance was evaluated for an outcome of major adverse cardiac events (MACEs) at 30 days.
RESULTS: Between November 2014 and April 2018, 1054 patients were recruited, of whom 960 (mean 64 (SD 15) years, 42% women) were eligible for analysis and 255 (26%) experienced a MACE at 30 days. A HEART score of ≤3 identified 279 (29%) as low risk with a negative predictive value of 93.5% (95% CI 90.0% to 95.9%) for the contemporary assay and 91.4% (95% CI 87.5% to 94.2%) for the high-sensitivity assay. A modified HEART score of ≤3 using the limit of detection of the high-sensitivity assay identified 194 (20%) patients as low risk with a negative predictive value of 95.9% (95% CI 92.1% to 97.9%). A HEART score of ≥7 using either assay gave a lower positive predictive value than using the upper reference limit of either cardiac troponin assay alone.
CONCLUSIONS: A HEART score derived by paramedics in the prehospital setting, even when modified to harness the precision of a high-sensitivity assay, does not allow safe rule-out of myocardial infarction or enhanced rule-in compared with cardiac troponin testing alone.
| Original language | English |
|---|---|
| Pages (from-to) | 474-481 |
| Number of pages | 8 |
| Journal | Emergency Medicine Journal |
| Volume | 40 |
| Issue number | 7 |
| Early online date | 2 Jun 2023 |
| DOIs | |
| Publication status | Published - Jul 2023 |
Bibliographical note
FundingThe study was supported financially by the Digital Health & Care Institute (DHI) (reference DHI/MCADAM), Scotland, and by the NHS Grampian Endowment Fund (grant number N0042903). Samsung provided the POC devices and test discs, and the University of Aberdeen contributed to the design and administration of the study. The funders had no role in the study design, data collection, interpretation or writing of the report. JGC was supported by a National Research Scotland Clinical Research Fellowship. KL and NLM are supported by the British Heart Foundation through a Clinical Research Training Fellowship (FS/18/25/33454) and a Chair Award, Programme Grant, and Research Excellence Award (CH/F/21/90010, RG/20/10/34966 and RE/18/5/34216), respectively.