Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.
Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina.
Prehosp Emerg Care. 2023;27(4):482-487. doi: 10.1080/10903127.2022.2036883. Epub 2022 Feb 17.
Emergency medical services (EMS) assesses millions of patients with chest pain each year. However, tools validated to risk stratify patients for acute coronary syndrome (ACS) and pulmonary embolism (PE) have not been translated to the prehospital setting. The objective of this study is to assess the prehospital performance of risk stratification scores for 30-day major adverse cardiac events (MACE) and PE.
A prospective observational cohort study of patients ≥21 years of age with acute chest pain who were transported by EMS in two North Carolina (NC) counties was conducted from 18 April 2018-2 January 2019. In this convenience sample, paramedics completed HEAR (history, electrocardiogram, age, risk factor), ED Assessment of Chest Pain Score (EDACS), Revised Geneva Score (RGS), and pulmonary embolism rule-out criteria (PERC) assessments on each patient. MACE (all-cause death, myocardial infarction, and revascularization) and PE at 30 days were determined by hospital records and NC Death Index. The positive (+LR) and negative likelihood ratios (-LR) of the risk scores for 30-day MACE and PE were calculated.
During the study period, 82.1% (687/837) patients had all four risk score assessments. The cohort was 51.1% (351/687) female, 49.5% (340/687) African American, and had a mean age of 55.0 years (SD 16.0). At 30 days, MACE occurred in 7.4% (51/687), PE occurred in 0.9% (6/687), and the combined outcome occurred in 8.2% (56/687). The HEAR score had a - LR of 0.46 (95% CI 0.27-0.78) and + LR of 1.48 (95% CI 1.26-1.74) for 30-day MACE. EDACS had a - LR of 0.61 (95% CI 0.46-0.81) and + LR of 2.53 (95% CI 1.86-3.46) for 30-day MACE. The PERC score had a - LR of 0 (95% CI 0.0-1.4) and a + LR of 1.38 (95% CI 1.32-1.45) for 30-day PE. The RGS score had a - LR of 0 (95% CI 0.0-0.65) and a + LR of 2.36 (95% CI 2.16-2.57) for 30-day PE. The combination of a low-risk HEAR score and negative PERC evaluation had a - LR of 0.25 (95% CI 0.08-0.76) and a + LR of 1.21 (95% CI 1.21-1.30) for 30-day MACE or PE.
The combination of a paramedic-obtained HEAR score and PERC evaluation performed best to exclude 30-day MACE and PE but was not sufficient for directing prehospital decision making.
急救医疗服务 (EMS) 每年评估数以百万计的胸痛患者。然而，用于对急性冠状动脉综合征 (ACS) 和肺栓塞 (PE) 进行风险分层的工具尚未转化为院前环境。本研究的目的是评估用于 30 天主要不良心脏事件 (MACE) 和 PE 的风险分层评分的院前表现。
对 2018 年 4 月 18 日至 2019 年 1 月 2 日期间在北卡罗来纳州 (NC) 的两个县由 EMS 转运的年龄≥21 岁的急性胸痛患者进行前瞻性观察性队列研究。在这个方便的样本中，护理人员对每位患者进行 HEAR（病史、心电图、年龄、危险因素）、ED 胸痛评分 (EDACS)、修订的日内瓦评分 (RGS) 和肺栓塞排除标准 (PERC) 评估。通过医院记录和 NC 死亡指数确定 30 天内的 MACE（全因死亡、心肌梗死和血运重建）和 PE。计算风险评分的 30 天 MACE 和 PE 的阳性 (+LR) 和阴性似然比 (-LR)。
在研究期间，82.1%（687/837）的患者进行了所有四项风险评分评估。队列中 51.1%（351/687）为女性，49.5%（340/687）为非裔美国人，平均年龄为 55.0 岁（SD 16.0）。在 30 天内，发生 MACE 51 例（7.4%），PE 6 例（0.9%），联合结局 56 例（8.2%）。HEAR 评分的 30 天 MACE 的- LR 为 0.46（95%CI 0.27-0.78），+ LR 为 1.48（95%CI 1.26-1.74）。EDACS 的 30 天 MACE 的- LR 为 0.61（95%CI 0.46-0.81），+ LR 为 2.53（95%CI 1.86-3.46）。PERC 评分的 30 天 PE 的- LR 为 0（95%CI 0.0-1.4），+ LR 为 1.38（95%CI 1.32-1.45）。RGS 评分的 30 天 PE 的- LR 为 0（95%CI 0.0-0.65），+ LR 为 2.36（95%CI 2.16-2.57）。低风险 HEAR 评分和阴性 PERC 评估的组合对 30 天 MACE 或 PE 的- LR 为 0.25（95%CI 0.08-0.76），+ LR 为 1.21（95%CI 1.21-1.30）。
护理人员获得的 HEAR 评分和 PERC 评估的组合可最好地排除 30 天的 MACE 和 PE，但不足以指导院前决策。
