Prehospital Observational research Rotterdam Troponin. observational comparative study to the use of HEART score in the prehospital phase

On a yearly base there are about 100.000 ambulance dispatches each year in the
greater Rotterdam area. Every year, more than 17,000 patients are diagnosed
with thoracic complaints that could be associated with acute coronary syndrome
(ACS). More than 15,000 of these patients are transported to a hospital. This
is a significant part of the total amount of ambulance deployment (Ambulance
Care Rotterdam-Rijnmond [AZRR], 2016).

The complaints that are appropriate for an ACS consist of chest pain or other
thoracic complaints, appearance to arms, jaws or shoulder blades, with or
without vegetative symptoms. ACS cases include acute myocardial infarction
(AMI) that can occur with and without ST elevation (STEMI and NSTEMI) and
unstable angina pectoris (IAP). In addition to the ACS, there is a wide variety
of pathologies that cause complaints that resemble an ACS, but have another
cause. This may include gastrointestinal disorders, panic attacks, pulmonary
embolisms and many other causes (Ishak et al., 2017). In order to confirm or
exclude an ACS, besides historie, physical examination and electrocardiogram
(EKG), troponin determination is of great importance in the diagnostic process.
At present, it is not possible to determine prehospital troponin. As a result,
there is a delay between the occurrence of the complaints and the onset of the
specific therapy such as medication and / or revascularisation, which may
affect morbidity and mortality (Milosevic et al., 2016).

It seems obvious that a significant part of all ambulances deployments which
presents themselves as thoracic complaints may be of a cardiologic nature. Due
to the limited prehospital diagnostic possibilities of these category patients
(who present themselves with thoracic pain associated with acute coronary
syndrome (ACS), it is not possible to confirm or exclude an ACS in this first
phase. The result is that this patients can be transported to a hospital which
is not able to provide the optimal care (non-intervention versus intervention
center).

The prehospital confirmation or exclusion of an ACS can positively contribute
to decision-making and the quality of care. Based on risk stratification using
the HEART score, the ambulancenurse can determine the risk profile of the
patient and rule out or diagnose of ACS. The HEART score consists of five
components, History, EKG, Age, Risk Factors and Troponin. Each part is scored
and a total score is generated. The HEART score is a validated risk assessment
instrument. Determining a troponin is an important part of the standard care
for patients with ACS symptoms.
With the implementation of the prehospital HEART score, the Troponin is done in
the ambulance or at the patients home.

The HEART-score is an validated risk stratification tool to predict the change
of having MACE in patient with chest pain on the emergency department (Backus
et al., 2013; Poldervaart et al., 2017). The heart score stands for History,
ECG, Age, Risk factors en Troponin.
Recently is in the FAMOUS TRIAGE a modified HEART score developed, where the
HEART-score is not taking on the ED but already in prehospital phase (home or
ambulance) (Ishak et al., 2015; Ishak et al., 2017). In this study blood was
taken at home or at the ambulance and troponin was determined retrospective in
the hospital. To use modified HEART-score in the prehospital phase, the
troponin also most be taking and determined at home or in the ambulance with a
POC devise.

Goal of this trial is validation of the modified HEART-score, with taken and
determined troponin with a POC in the prehospital phase.

This is expected not only to improve patient safety, but can also have a
positive impact on costs and workload.

For this study only feasibility en reliability of the use of HEART-score is
tested in de prehospital phase. one blood sample is taking for troponin, but is
blinded on de point of care testing voor de nurses. The treatment is usual care
conform LPA 8.1. The blood sample for troponin goes to the laboratorium from
the hospital for usual troponin assessment.

Reliability of prehospital triage with HEART-score in patients with thoracic
complaints/pain appropriate to a suspicious ACS

Observational validation study

no extra risk
only standard care (Troponin) only earlier in the proces

The blood sample goes with the patient to the hospital for usual Troponin
assessment and is directly destroyed after Troponin assessment. The PI can get
the troponin results with consent of the patient from the hospital. one drop
blood is used for point of care troponin testing. this point of care test is
blinded for the nurses.