在急诊初级护理中充分识别低风险胸痛：基于两个欧洲队列评估preHEAR(T)的性能。

Adequately identifying low-risk chest pain in emergency primary care: evaluating the performance of preHEAR(T) based on two European cohorts.

作者信息

Johannessen Tonje R, Melessen Indra M B, Vallersnes Odd Martin, Manten Amy, Halvorsen Sigrun, Atar Dan, Harskamp Ralf E

机构信息

Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway.

Department of Emergency General Practice, Oslo Accident and Emergency Outpatient Clinic, City of Oslo Health Agency, Oslo, Norway.

出版信息

Open Heart. 2025 Jul 27;12(2):e003362. doi: 10.1136/openhrt-2025-003362.

DOI:10.1136/openhrt-2025-003362

PMID:40716792

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC12306204/

Abstract

BACKGROUND

Differentiating cardiac from non-cardiac acute chest pain poses a diagnostic challenge, especially in primary care. The History, ECG, Age, Risk factors and Troponin level (HEART) score aid in risk stratification in hospitals, while the prehospital HEART (preHEART) score was refined for paramedics' use. However, its accuracy in emergency primary care has not been studied. This study evaluates the preHEAR(T) score, with and without high-sensitivity cardiac troponin (hs-cTn), as a tool to rule out acute myocardial infarction (MI) in emergency primary care.

METHODS

Retrospective data from two European cohorts were analysed, namely the One-hoUr Troponin in a low-prevalence population of Acute Coronary Syndrome (OUT-ACS) study (1711 patients) at a Norwegian emergency primary care centre (2016-2018) and the TRiage of Acute Chest pain Evaluated in urgent primary care (TRACE) study (664 patients) at a Dutch emergency primary care centre (2017). The preHEAR (without hs-cTn) score was evaluated in both cohorts. The preHEART score was assessed in OUT-ACS only, as the TRACE study did not measure troponins. The threshold of ≤3 points has previously been determined as low risk for acute MI (AMI) and optimal for rule-out purposes. The primary outcome was diagnostic performance for ruling out MI, and the secondary outcome was the composite of 90-day AMI or all-cause death.

RESULTS

In OUT-ACS, 3.6% of patients had an AMI (median age 56 years (45-68); 47.7% female), and 3% in TRACE (median age 48 years (32-67); 56.9% female). PreHEAR identified 49.3% (OUT-ACS) and 82.7% (TRACE) as low risk, while preHEART identified 33.6% (OUT-ACS) as low risk. Sensitivity/specificity for AMI were 63.9% (95% CI 50.6 to 75.8)/49.8% (95% CI 47.3 to 52.7) (OUT-ACS) and 65% (95% CI 40.8 to 84.6)/84.2% (95% CI 81.1 to 86.9) (TRACE) for preHEAR and 93.4% (95% CI 84.1 to 98.2)/34.6% (95% CI 32.2 to 37) for preHEART. For the secondary outcome, similar diagnostic performance metrics were found. There were four missed AMI cases in the low-risk preHEART group, who were all female.

CONCLUSION

Neither the preHEAR nor preHEART scores provide sufficient rule out safety in emergency primary care and may particularly underestimate AMI risk in females.

TRIAL REGISTRATION NUMBER

OUT-ACS: clinicaltrials.gov NCT02983123.

TRACE

Netherlands Trial Registry (NL-OMON20102); https://onderzoekmetmensen.nl/nl/trial/20102.

摘要

背景

区分心脏性与非心脏性急性胸痛是一项诊断挑战，在初级医疗保健中尤其如此。病史、心电图、年龄、危险因素和肌钙蛋白水平（HEART）评分有助于医院进行风险分层，而院前HEART（preHEART）评分则是为护理人员使用而优化的。然而，其在急诊初级医疗保健中的准确性尚未得到研究。本研究评估了有和没有高敏心肌肌钙蛋白（hs-cTn）的preHEAR（T）评分作为在急诊初级医疗保健中排除急性心肌梗死（MI）的工具。

方法

分析了来自两个欧洲队列的回顾性数据，即挪威急诊初级医疗保健中心（2016 - 2018年）的低患病率急性冠状动脉综合征人群中的一小时肌钙蛋白（OUT - ACS）研究（1711例患者）和荷兰急诊初级医疗保健中心（2017年）的急性胸痛分诊在紧急初级医疗保健中的评估（TRACE）研究（664例患者）。在两个队列中评估了preHEAR（无hs-cTn）评分。仅在OUT - ACS中评估了preHEART评分，因为TRACE研究未检测肌钙蛋白。先前已确定≤3分的阈值为急性心肌梗死（AMI）的低风险且最适合排除目的。主要结局是排除MI的诊断性能，次要结局是90天AMI或全因死亡的复合结局。

结果

在OUT - ACS中，3.6%的患者发生AMI（中位年龄56岁（45 - 68岁）；47.7%为女性），在TRACE中为3%（中位年龄48岁（32 - 67岁）；56.9%为女性）。preHEAR将49.3%（OUT - ACS）和82.7%（TRACE）识别为低风险，而preHEART将33.6%（OUT - ACS）识别为低风险。preHEAR对AMI的敏感性/特异性分别为63.9%（95%CI 50.6至75.8）/49.8%（95%CI 47.3至52.7）（OUT - ACS）和65%（95%CI 40.8至84.6）/84.2%（95%CI 81.1至86.9）（TRACE），preHEART为93.4%（95%CI 84.1至98.2）/34.6%（95%CI 32.2至37）。对于次要结局，发现了类似的诊断性能指标。低风险preHEART组中有4例漏诊的AMI病例，均为女性。