Diagnostic Accuracy of Clinical Pathways for Suspected Acute Myocardial Infarction in the Out-of-Hospital Environment - 20/09/23
Abstract |
Study objective |
Chest pain is one of the most common reasons for emergency ambulance calls. Patients are routinely transported to the hospital to prevent acute myocardial infarction (AMI). We evaluated the diagnostic accuracy of clinical pathways in the out-of-hospital environment. The Troponin-only Manchester Acute Coronary Syndromes decision aid and History, ECG, Age, Risk Factors, Troponin score require cardiac troponin (cTn) measurement, whereas the History and ECG-only Manchester Acute Coronary Syndromes decision aid and History, ECG, Age, Risk Factors score do not.
Methods |
We conducted a prospective diagnostic accuracy study at 4 ambulance services and 12 emergency departments between February 2019 and March 2020. We included patients who received an emergency ambulance response in whom paramedics suspected AMI. Paramedics recorded the data required to calculate each decision aid and took venous blood samples in the out-of-hospital environment. Samples were tested using a point-of-care cTn assay (Roche cobas h232) within 4 hours. The target condition was a diagnosis of type 1 AMI, adjudicated by 2 investigators.
Results |
Of 817 included participants, 104 (12.8%) had AMI. Setting the cutoff at the lowest risk group, Troponin-only Manchester Acute Coronary Syndromes had 98.3% sensitivity (95% confidence interval 91.1% to 100%) and 25.5% specificity (21.4% to 29.8%) for type 1 AMI. History, ECG, Age, Risk Factors, Troponin had 86.4% sensitivity (75.0% to 98.4%) and 42.2% specificity (37.5% to 47.0%); History and ECG-only Manchester Acute Coronary Syndromes had 100% sensitivity (96.4% to 100%) and 3.1% specificity (1.9% to 4.7%), whereas History, ECG, Age, Risk Factors had 95.1% sensitivity (88.9% to 98.4%) and 12.1% specificity (9.8% to 14.8%).
Conclusion |
With point-of-care cTn testing, decision aids can identify patients at a low risk of type 1 AMI in the out-of-hospital environment. When used alongside clinical judgment, and with appropriate training, such tools may usefully enhance out-of-hospital risk stratification.
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| Please see page 440 for the Editor’s Capsule Summary of this article. |
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| Supervising editor: Steve Goodacre, PhD. Specific detailed information about possible conflict of interest for individual editors is available at editors. |
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| Author contributions: All authors met the criteria for authorship, having been involved in the design and conduct of the research, interpretation of data and critical editing of the final manuscript. Steve Bell was not involved in the design but was involved in the remainder of the study. Mark Hann was responsible for statistical analyses. Richard Body takes overall responsibility for the data. |
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| Data sharing statement: Please contact Richard Body for any queries regarding access to data. Reasonable requests for anonymous (de-identified) participant data that are in accordance with relevant regulatory approvals will be granted, from the date of publication for a period of 5 years after study completion. These data are currently stored securely and, to date, have not been published in a public repository. |
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| Authorship: 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). Richard Body has undertaken consultancy with Roche, Abbott, Siemens, Beckman Coulter, Radiometer, Aptamer Group, and LumiraDx; has recent research grants with Abbott Point of Care and Siemens; and has conducted research involving donation of reagents by Roche. Abdulrhman Alghamdi received funding from Abbott Point of Care and received donation of reagents from Roche Diagnostics International Ltd and LumiraDx. Edward Carlton has received speaker honoraria from Roche Diagnostics and is a National Institute for Health Research Advanced Fellow. Jamie Cooper is supported by NHS Research Scotland. Alex Thompson has undertaken consultancy with Siemens and Perspectum. The other authors have stated that no such relationships exist. This study was funded by the National Institute for Health Research, Research for Patient Benefit scheme, research grant reference PB-PG-1216-20034. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. Roche Diagnostics donated reagents for the purpose of this research. |
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| Trial registration number: NCT03561051. |
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Vol 82 - N° 4
P. 439-448 - octobre 2023 Retour au numéro
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