Emergency Department, Aberdeen Royal Infirmary, Aberdeen, United Kingdom; Department of Applied Medicine, University of Aberdeen, Aberdeen, United Kingdom.
Emergency Department, Aberdeen Royal Infirmary, Aberdeen, United Kingdom; Department of Applied Medicine, University of Aberdeen, Aberdeen, United Kingdom.
Ann Emerg Med. 2021 Jun;77(6):575-588. doi: 10.1016/j.annemergmed.2021.01.012. Epub 2021 Apr 27.
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.
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.
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%).
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.
确定院外风险分层是否可以识别出胸痛患者的低危和高危人群，以避免入院或辅助直接转至心脏中心。
护理人员前瞻性地招募心电图无诊断性 ST 段抬高的疑似急性冠状动脉综合征患者。同时记录病史、心电图、年龄和危险因素（HEAR）评分，并采集院外样本，使用即时检测设备测量心脏肌钙蛋白 I（cTnI）水平，以便计算病史、心电图、年龄、危险因素和肌钙蛋白（HEART）评分。HEAR 和 HEART 评分≤3 和≥7 定义为 30 天内主要不良心脏事件的低危和高危。
在 1054 例患者（64 岁[标准差 15 岁]；42%为女性）中，284 例（27%）在 30 天内发生主要不良心脏事件。所有患者均计算了 HEAR 评分，357 例（34%）进行了即时检测 cTnI 检测。HEAR 评分≤3 识别出 32%的患者（334/1054）为低危，敏感性为 84.9%（95%置信区间[CI]80.7%至 89%），而评分≥7 仅识别出 3%的患者（30/1054）为高危，特异性为 98.7%（95%CI 97.9%至 99.5%）。即时检测 HEART 评分≤3 识别出相似比例的低危患者（30%），敏感性为 87.0%（95%CI 80.7%至 93.4%），而评分≥7 识别出 14%的高危患者，特异性为 94.8%（95%CI 92.0%至 97.5%）。
护理人员可以使用 HEAR 评分进行风险分层，但即使结合院外即时检测 cTnI 检测，HEART 评分也不能安全排除主要不良心脏事件，且仅有一小部分患者被识别为高危。
