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Performance of a prehospital HEART score in patients with possible myocardial infarction: a prospective evaluation
  1. Jamie G Cooper1,2,
  2. James Ferguson1,
  3. Lorna A Donaldson3,
  4. Kim M M Black1,
  5. Kate J Livock1,
  6. Judith L Horrill1,
  7. Elaine M Davidson4,
  8. Neil W Scott5,
  9. Amanda J Lee5,
  10. Takeshi Fujisawa6,7,
  11. Kuan Ken Lee6,
  12. Atul Anand6,
  13. Anoop S V Shah8,
  14. Nicholas L Mills6,9
  1. 1 Emergency Department, Aberdeen Royal Infirmary, Aberdeen, UK
  2. 2 School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
  3. 3 Department of Research Development and Innovation, Scottish Ambulance Service, Edinburgh, UK
  4. 4 Department of Clinical Biochemistry, Aberdeen Royal Infirmary, Aberdeen, UK
  5. 5 Medical Statistics Team, University of Aberdeen, Aberdeen, UK
  6. 6 BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
  7. 7 BHF Cardiovascular Biomarker Laboratory, University of Edinburgh, Edinburgh, UK
  8. 8 Department of Non Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
  9. 9 Usher Institute, University of Edinburgh, Edinburgh, UK
  1. Correspondence to Dr Jamie G Cooper, Emergency Department, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, UK; jamie.cooper2{at}


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.

  • pre-hospital
  • acute myocardial infarct
  • admission avoidance
  • diagnostic tests
  • care systems

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information. All relevant study data is included within the article and the online supplemental material.

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Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information. All relevant study data is included within the article and the online supplemental material.

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  • Handling editor Edward Carlton

  • Twitter @JamieCooperEM, @foggleberg

  • Presented at The preliminary results of the ACCESS study were presented at the Royal College of Emergency Medicine Annual Scientific Conference on 1–3 October 2019 in Gateshead, UK, and further results were presented virtually to the European Congress on Emergency Medicine on 19–22 September 2020.

  • Contributors 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, KL, 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 manuscript. All authors reviewed the manuscript critically for intellectually important content, provided their final approval of the version to be submitted and were accountable for the work. JGC is the guarantor of the study.

  • Funding The 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.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.