院前HEAR和HE-MACS评分对30天不良心脏事件的比较。
Prehospital Comparison of the HEAR and HE-MACS Scores for 30-Day Adverse Cardiac Events.
作者信息
Popp Lucas M, Ashburn Nicklaus P, Paradee Brennan E, Snavely Anna C, O'Neill James C, Boyer Kate M, Body Richard, Mahler Simon A, Stopyra Jason P
机构信息
Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.
Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.
出版信息
Prehosp Emerg Care. 2024;28(1):23-29. doi: 10.1080/10903127.2022.2142343. Epub 2022 Nov 29.
OBJECTIVE
The History, Electrocardiogram (ECG), Age, and Risk factor (HEAR) and History and ECG-only Manchester Acute Coronary Syndromes (HE-MACS) risk scores can risk stratify chest pain patients without troponin measures. The objective of this study was to determine if either risk score could achieve the ≥99% negative predictive value (NPV) required to rule out major adverse cardiovascular events (MACE; a composite of all-cause death, myocardial infarction, or coronary revascularization) at 30 days or the ≥50% positive predictive value (PPV) indicative of a patient possibly needing interventional cardiology.
METHODS
We performed a pre-planned secondary analysis of the prospective multisite PARAHEART ( = 462, 12/2016-1/2018) and RESCUE ( = 767, 4/2018-1/2019) trials, which accrued adults ≥21 years old with acute non-traumatic chest pain transported by emergency medical services (EMS). Paramedics prospectively completed risk assessment forms. Very low risk was defined by a HEAR score of 0-1 or HE-MACS probability <4%. The primary outcome was 30-day MACE, which was determined by adjudication (PARAHEART) or electronic record review (RESCUE). NPV and PPV with exact 95% confidence intervals (95%CI) for 30-day MACE were calculated for each risk score and compared using McNemar's tests.
RESULTS
Among the PARAHEART and RESCUE cohorts, 30-day MACE occurred in 18.8% (87/462) and 6.9% (53/767) of patients, respectively. In PARAHEART, 7.8% (36/462) were very low risk by HEAR score vs. 7.8% (36/462) by HE-MACS ( = 1.0). The HEAR score had a NPV of 97.2% (95%CI 91.9-100.0) vs. 91.7% (95%CI 82.6-100.0) for HE-MACS ( = 0.15). The HEAR and HE-MACS PPVs were similar [46.4% (95%CI 28.0-64.9) vs. 33.3% (95%CI 13.2-53.5) ( = 0.26)]. In RESCUE, the HEAR score identified 14.2% (109/767) as low risk compared to 8.3% (64/767) by HE-MACS ( < 0.001). In this cohort, the HEAR and HE-MACS scores had similar NPVs [98.2% (95%CI 95.7-100.0) vs. 98.4% (95%CI 95.4-100.0) ( = 0.89)] and PPVs [16.2% (95%CI 6.2-32.0) vs. 22.6% (95%CI 12.3-36.2) ( = 0.41)].
CONCLUSIONS
In two prehospital chest pain cohorts, neither the HEAR score nor HE-MACS achieved sufficient NPV or PPV to rule out or rule in 30-day MACE.
目的
病史、心电图（ECG）、年龄和风险因素（HEAR）风险评分以及仅基于病史和心电图的曼彻斯特急性冠状动脉综合征（HE-MACS）风险评分可在不检测肌钙蛋白的情况下对胸痛患者进行风险分层。本研究的目的是确定这两种风险评分是否能够达到在30天时排除主要不良心血管事件（MACE；全因死亡、心肌梗死或冠状动脉血运重建的复合终点）所需的≥99%的阴性预测值（NPV），或达到≥50%的阳性预测值（PPV），后者表明患者可能需要介入心脏病学治疗。
方法
我们对前瞻性多中心PARAHEART试验（n = 462，2016年12月 - 2018年1月）和RESCUE试验（n = 767，2018年4月 - 2019年1月）进行了预先计划的二次分析，这两项试验纳入了年龄≥21岁、由紧急医疗服务（EMS）转运的急性非创伤性胸痛成人患者。护理人员前瞻性地完成风险评估表。极低风险定义为HEAR评分为0 - 1或HE-MACS概率<4%。主要结局为30天MACE，通过判定（PARAHEART）或电子记录审查（RESCUE）确定。计算每个风险评分30天MACE的NPV和PPV以及精确的95%置信区间（95%CI），并使用McNemar检验进行比较。
结果
在PARAHEART和RESCUE队列中，30天MACE分别发生在18.8%（87/462）和6.9%（53/767）的患者中。在PARAHEART中，HEAR评分显示7.8%（36/462）为极低风险，HE-MACS显示为7.8%（36/462）（p = 1.0）。HEAR评分的NPV为97.2%（95%CI 91.9 - 100.0），而HE-MACS为91.7%（95%CI 82.6 - 100.0）（p = 0.15）。HEAR和HE-MACS的PPV相似[46.4%（95%CI 28.0 - 64.9）对33.3%（95%CI 13.2 - 53.5）（p = 0.26）]。在RESCUE中，HEAR评分确定14.2%（109/767）为低风险，而HE-MACS为8.3%（64/767）（p < 0.001）。在该队列中，HEAR和HE-MACS评分的NPV相似[98.2%（95%CI 95.7 - 100.0）对98.4%（95%CI 95.4 - 100.0）（p = 0.89）]，PPV也相似[16.2%（95%CI 6.2 - 32.0）对22.6%（95%CI 12.3 - 36.2）（p = 0.41）]。
结论
在两个院前胸痛队列中，HEAR评分和HE-MACS评分均未达到足够的NPV或PPV以排除或判定30天MACE。
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