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  • External validation of the preHEART score and comparison with current clinical risk scores for prehospital risk assessment in patients with suspected NSTE-ACS

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Original research
External validation of the preHEART score and comparison with current clinical risk scores for prehospital risk assessment in patients with suspected NSTE-ACS
  1. Jesse P A Demandt1,
  2. Arjan Koks2,
  3. Dennis Sagel3,
  4. Rutger Haest4,
  5. Eric Heijmen5,
  6. Eric Thijssen6,
  7. Mohamed el Farissi1,
  8. Rob Eerdekens1,
  9. Pim van der Harst7,
  10. Marcel van ’t Veer1,
  11. Lukas Dekker1,8,
  12. Pim Tonino1,8,
  13. Pieter J Vlaar1
  1. 1 Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
  2. 2 GGD Brabant-Zuidoost, Eindhoven, The Netherlands
  3. 3 Regional Ambulance Services, Groningen, The Netherlands
  4. 4 Department of Cardiology, St Anna Hospital, Geldrop, The Netherlands
  5. 5 Department of Cardiology, Elkerliek Hospital, Helmond, The Netherlands
  6. 6 Department of Cardiology, Maxima Medical Centre, Veldhoven, The Netherlands
  7. 7 Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
  8. 8 Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
  1. Correspondence to Dr Pieter J Vlaar; Pieter-Jan.vlaar{at}catharinaziekenhuis.nl

Abstract

Background Emergency Medical Services (EMS) studies have shown that prehospital risk stratification and triage decisions in patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) can be improved using clinical risk scores with point-of-care (POC) troponin. In current EMS studies, three different clinical risk scores are used in patients suspected of NSTE-ACS: the prehospital History, ECG, Age, Risk and Troponin (preHEART) score, History, ECG, Age, Risk and Troponin (HEART) score and Troponin-only Manchester Acute Coronary Syndromes (T-MACS). The preHEART score lacks external validation and there exists no prospective comparative analysis of the different risk scores within the prehospital setting. The aim of this analysis is to externally validate the preHEART score and compare the diagnostic performance of the these three clinical risk scores and POC-troponin.

Methods Prespecified analysis from a prospective, multicentre, cohort study in patients with suspected NSTE-ACS who were transported to an ED between April 2021 and December 2022 in the Netherlands. Risk stratification is performed by EMS personnel using preHEART, HEART, T-MACS and POC-troponin. The primary end point was the hospital diagnosis of NSTE-ACS. The diagnostic performance was expressed as area under the receiver operating characteristic (AUROC), sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV).

Results A total of 823 patients were included for external validation of the preHEART score, final hospital diagnosis of NSTE-ACS was made in 29% (n=235). The preHEART score classified 27% as low risk, with a sensitivity of 92.8% (95% CI 88.7 to 95.7) and NPV of 92.3% (95% CI 88.3 to 95.1). The preHEART classified 9% of the patients as high risk, with a specificity of 98.5% (95% CI 97.1 to 99.3) and PPV of 87.7% (95% CI 78.3 to 93.4). Data for comparing clinical risk scores and POC-troponin were available in 316 patients. No difference was found between the preHEART score and HEART score (AUROC 0.83 (95% CI 0.78 to 0.87) vs AUROC 0.80 (95% CI 0.74 to 0.85), p=0.19), and both were superior compared with T-MACS (AUROC 0.72 (95% CI 0.66 to 0.79), p≤0.001 and p=0.03, respectively) and POC-troponin measurement alone (AUROC 0.71 (95% CI 0.64 to 0.78), p<0.001 and p=0.01, respectively).

Conclusion On external validation, the preHEART demonstrates good overall diagnostic performance as a prehospital risk stratification tool. Both the preHEART and HEART scores have better overall diagnostic performance compared with T-MACS and sole POC-troponin measurement. These data support the implementation of clinical risk scores in prehospital clinical pathways.

Trial registration number NCT05243485.

  • acute coronary syndrome
  • pre-hospital care
  • emergency ambulance systems
  • risk management
  • point-of-care testing

Data availability statement

Data are available on reasonable request. The data that support the findings of this study will be made available 1 year after publication on reasonable request from the corresponding author (PJV).

https://doi.org/10.1136/emermed-2023-213866

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    Data availability statement

    Data are available on reasonable request. The data that support the findings of this study will be made available 1 year after publication on reasonable request from the corresponding author (PJV).

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    Footnotes

    • Handling editor Edward Carlton

    • Correction notice Since this paper first published, figure 1 has been replaced with the correct artwork.

    • Contributors Study planning and design: JPAD, AK, DS, RH, EH, HT, PvdH, MvV, LD, PT, PJV. Analysis and interpretation of results: JPAD, AK, MeF, RE, MvV, LD, PT, PJV. Draft manuscript preparation: JPAD, AK, DS, RH, EH, HT, MeF, RE, PvdH, MvV, LD, PT, PJV. Guarantor for overall content: JPAD, PJV.

    • Funding The study is funded by ZonMw, the Dutch Organisation for Health Research and Development, specifically through the grant program 'Topspecialistische Zorg en Onderzoek' (grant number 10070012010001).

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the 'Methods' section for further details.

    • 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.