The Ambulance Cardiac Chest Pain Evaluation in Scotland Study (ACCESS): A Prospective Cohort Study - 21/05/21
, James Ferguson, MBChB a, b, Lorna A. Donaldson c, Kim M.M. Black a, Kate J. Livock a, Judith L. Horrill, MSc a, Elaine M. Davidson, MSc, PhD d, Neil W. Scott, MSc, PhD e, Amanda J. Lee, PhD e, Takeshi Fujisawa, PhD f, g, Kuan Ken Lee, MD f, Atul Anand, MD, PhD f, Anoop S.V. Shah, MD, PhD f, h, Nicholas L. Mills, MD, PhD f, g, hAbstract |
Study objective |
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.
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| Please see page 576 for the Editor’s Capsule Summary of this article. |
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| Supervising editor: Keith A. Marill, MD, MS. Specific detailed information about possible conflict of interest for individual editors is available at editors. |
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| Author contributions: JGC, JF, KJL, and EMD conceived the study and its design. JGC, JF, LAD, KMMB, KJL, and JLH developed and delivered the paramedic training. JGC, LAD, KMMB, JLH, EMD, TF, KKL, AA, and ASVS acquired the data. JGC, NWS, and AJL performed the analysis. JGC, JF, NWS, AJL, and NLM interpreted the data. JGC and NLM drafted the article. All authors reviewed the article critically for intellectually important content and provided their final approval of the version to be submitted. JGC takes responsibility for the paper as a whole. |
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| All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. |
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| Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. The study was supported financially by the Digital Health & Care Institute (DHI), Scotland and by the National Health Service Grampian Endowment Fund. Samsung provided the point-of-care devices and test discs and the University of Aberdeen contributed to the design and administration of the study. Dr. Cooper was supported by a National Research Scotland Clinical Research Fellowship. Prof. Mills and Dr. Lee are supported by the British Heart Foundation through the Butler Senior Clinical Research Fellowship (FS/16/14/32023) and a Clinical Research Training Fellowship (FS/18/25/33454), respectively. |
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| Trial registration number: UIN 2671 |
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| The funders had no role in study design, data collection, or interpretation, or in the writing of the report. |
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Vol 77 - N° 6
P. 575-588 - juin 2021 Retour au numéro
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