Pre-hospital point-of-care troponin and paramedic assessment in patients with chest pain without ST-elevation (pilot study)

A cluster randomised controlled trial of 1,200 participants to assess the feasibility and acceptability of pre-hospital risk assessment of non-traumatic chest pain patients, using a risk assessment tool and point-of care troponin testing.

Chief Investigators

Prof Dion Stub, Prof Karen Smith, Dr Ziad Nehme

Funding source

Heart Foundation Vanguard Grant

Estimated completion date

March 2024

Background

Early identification of Acute Coronary Syndrome (ACS, commonly known as “heart attack”) is key to favourable outcomes. A major challenge to date has been delayed diagnosis taking place in the hospital, significantly impeding time-dependant treatments.

We’ve used meta-linkage of over >2million patient records to show that only a small percentage of chest pain patients present to emergency medical services with ACS and abnormal ECG findings. The remainder may present with ACS without abnormal ECG traces, (still requiring urgent cardiac intervention), or with stable coronary disease or non-cardiac chest pain (not requiring urgent cardiac intervention).

The HEART score risk assessment tool has shown benefit in assessing and triaging patients presenting with chest pain when used within the Emergency Department setting. Point-of-care troponin testing has similarly yielded great benefits in rapidly diagnosing ACS in the same context.

This pilot study will bring these two components out of the Emergency Department, and incorporate them into the pre-hospital setting, in an attempt to reduce delays in vital diagnosis and treatment.

It is estimated that 25 ambulance teams in Victoria will transport 1,200 chest pain patients over a 14-month period, who could potentially be included in this study.

Aim

To assess the feasibility of prehospital risk assessment by paramedics in patients presenting with non-traumatic chest pain, using the HEART score risk stratification tool combined with a point-of-care troponin measurement.

Outputs to date

Dawson LP, Andrew E, Nehme Z, Bloom J, Okyere D, Cox S, Anderson D, Stephenson M, Lefkovits J, Taylor AJ, Kaye D, Smith K, Stub D. Risk-standardized mortality metric to monitor hospital performance for chest pain presentations. Eur Heart J Qual Care Clin Outcomes. 2022 Oct 4:qcac062. doi: 10.1093/ehjqcco/qcac062. Epub ahead of print.

Dawson LP, Andrew E, Stephenson M, Nehme Z, Bloom J, Cox S, Anderson D, Lefkovits J, Taylor AJ, Kaye D, Smith K, Stub D. The influence of ambulance offload time on 30-day risks of death and re-presentation for patients with chest pain. Med J Aust. 2022 Sep 5;217(5):253-259. doi: 10.5694/mja2.51613. Epub 2022 Jun 23.

Dawson LP, Smith K, Cullen L, Nehme Z, Lefkovits J, Taylor AJ, Stub D. Care Models for Acute Chest Pain That Improve Outcomes and Efficiency: JACC State-of-the-Art Review. J Am Coll Cardiol. 2022 Jun 14;79(23):2333-2348. doi: 10.1016/j.jacc.2022.03.380.

Dawson LP, Andrew E, Nehme Z, Bloom J, Liew D, Cox S, Anderson D, Stephenson M, Lefkovits J, Taylor AJ, Kaye D, Cullen L, Smith K, Stub D. Development and validation of a comprehensive early risk prediction model for patients with undifferentiated acute chest pain. Int J Cardiol Heart Vasc. 2022 Apr 28;40:101043. doi: 10.1016/j.ijcha.2022.101043.

Dawson LP, Andrew E, Nehme Z, Bloom J, Okyere D, Cox S, Anderson D, Stephenson M, Lefkovits J, Taylor AJ, Kaye D, Smith K, Stub D. Incidence, diagnoses and outcomes of ambulance attendances for chest pain: a population-based cohort study. Ann Epidemiol. 2022 Aug;72:32-39. doi: 10.1016/j.annepidem.2022.04.010. Epub 2022 May 2.

Dawson LP, Andrew E, Nehme Z, Bloom J, Biswas S, Cox S, Anderson D, Stephenson M, Lefkovits J, Taylor AJ, Kaye D, Smith K, Stub D. Association of Socioeconomic Status With Outcomes and Care Quality in Patients Presenting With Undifferentiated Chest Pain in the Setting of Universal Health Care Coverage. J Am Heart Assoc. 2022 Apr 5;11(7):e024923. doi: 10.1161/JAHA.121.024923. Epub 2022 Mar 24.