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Background: This study assesses how ambulance paramedics using the modified HEART-score with a point-of-care cardiac troponin (cTn) compare to the emergency physicians using the modified HEART-score with a high-sensitive cTn (hs-cTn) in patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS), focusing on interobserver agreement and diagnostic performance. Methods: In this prospective multicenter cohort, we compare four cTn testing strategies (serial point of care and hs-cTn cTn measurement) with and without the HEART-score. Outcomes include the HEART-score's interobserver agreement, NSTE-ACS at discharge, major adverse cardiovascular events (MACE) after 30 days, and diagnostic accuracy of the different strategies. Conclusion: The POPular HEART study aims to improve NSTE-ACS diagnostic pathways, promoting pre-hospital detection and ruling out of NSTE-ACS to minimize unnecessary hospitalizations and associated costs. Clinical Trial Registration:NCT04851418 (ClinicalTrials.gov) Many people visit the emergency department (ED) due to chest pain, often worried about the possibility of a heart attack. While acute heart attacks can often be detected through an electrocardiogram (ECG; a test of the heart's electrical activity), a significant number of patients with a heart attack have a normal ECG. These patients require further testing to measure cardiac troponin (cTn; an indicator of heart damage) in the hospital to rule out a heart attack, known as non-ST-elevation acute coronary syndrome (NSTE-ACS). To improve diagnosis and care for these patients, we compared two approaches: ambulance paramedics using a quick bedside cTn test and the HEART-score, versus hospital doctors using a more sensitive cTn test with the HEART-score. The HEART score combines factors like the patient's medical history, ECG results, age, risk factors, and cTn levels to assess the risk of heart problems. In this comparison, the key difference lies in how cTn levels are measured – either through a quick finger prick test in an ambulance using a point-of-care device or a more detailed analysis in a hospital laboratory. We focused on patients visited by emergency medical services for chest pain suspected of a heart attack and transported to the hospital. We assessed the quick bedside test by paramedics and the detailed hospital test by doctors, alongside the use of the HEART score in both settings. Our evaluation looked at the agreement between these methods and their effectiveness in identifying or excluding an NSTE-ACS. Our research, known as the POPular HEART study, seeks to simplify the early identification or rule-out of an NSTE-ACS in patients with chest pain directly by ambulance. This approach aims to decrease unnecessary hospital admissions and reduce healthcare costs. We're exploring innovative methods to safely identify patients with a very low risk of NSTE-ACS in individuals with chest pain outside the hospital. Our objective is to safely minimize hospital admissions that may not be necessary, thereby saving resources. By doing so, we aim to alleviate the pressure on EDs and contribute to more cost-effective healthcare. Article highlights Background The study investigates the use of the HEART-score with point-of-care (POC) cTn testing by ambulance paramedics compared with HEART-score assessments with high-sensitive cTn (hs-cTn) by emergency physicians in patients suspected of having non-ST-elevation acute coronary syndrome (NSTE-ACS). Focuses on evaluating the interobserver agreement and diagnostic performance using the (modified) HEART-score. Methods A prospective, multicenter cohort study design. Comparison of four cTn testing strategies involving serial POC and hs-cTn measurements, with and without the modified HEART score. Including patients presenting with chest pain, visited by an ambulance, and transported to a hospital under a working diagnosis of NSTE-ACS. Primary outcomes measured were the HEART-score's interobserver agreement, the final diagnosis of NSTE-ACS at discharge, major adverse cardiovascular events (MACE) within 30 days, and the diagnostic accuracy of the testing methods. Conclusion The POPular HEART study aims to refine the diagnostic approach for NSTE-ACS, allowing for the early detection and exclusion of NSTE-ACS in the pre-hospital phase. The study seeks to reduce unnecessary hospital admissions and associated healthcare costs by improving the accuracy and reliability of NSTE-ACS diagnosis in the pre-hospital setting. Key findings The use of POC troponin testing by paramedics, when combined with the HEART score, can potentially streamline the diagnostic process for NSTE-ACS in the pre-hospital setting. High interobserver agreement suggests that the modified HEART-score is a reliable tool for assessing NSTE-ACS risk both pre-hospital and in-hospital. Early identification and exclusion of NSTE-ACS could significantly reduce unnecessary hospital stays, promoting more efficient use of healthcare resources. Implications for practice Implementing POC cTn testing and the HEART-score assessment in ambulance services could enhance the early diagnosis and management of NSTE-ACS. This approach may lead to a shift in how patients with suspected NSTE-ACS are triaged and managed, emphasizing the importance of accuracy and speed in the diagnostic process. Healthcare systems could see a reduction in the burden on emergency departments and in the overall costs associated with the care of patients with chest pain. Future directions Further research is needed to explore the scalability of implementing POC cTn testing and the HEART-score in diverse healthcare settings. Long-term studies could evaluate the impact of these diagnostic strategies on patient outcomes, healthcare costs, and system efficiency. Innovation in POC testing technology, reimbursement by health insurers and training for pre-hospital care providers will be critical to the widespread adoption of these strategies. [ABSTRACT FROM AUTHOR] |
