{
  "abstract": "Background Emergency Medical Services (EMS) patients with chest pain are often suspected of having non-ST-elevation acute coronary syndrome (NSTE-ACS). Current risk stratification protocols for NSTE-ACS have limitations, leading to a lack of a well-organised prehospital diagnostic pathway. Recent studies have demonstrated that using clinical risk scores (CRS) including point-of-care (POC)-troponin in the EMS can improve prehospital diagnostic pathways for suspected NSTE-ACS. The primary aim of this systematic review and individual patient data meta-analysis was to assess safety of low-risk stratification for suspected NSTE-ACS patients in the prehospital setting.Methods Prospective studies using CRS or POC-troponin for risk stratification in suspected NSTE-ACS patients within the EMS setting were included. Safety was assessed using sensitivity and negative predictive value (NPV) for patients identified as low risk, based on CRS or POC-troponin measurement, for three different endpoints within 30 days: (1) all-cause mortality, (2) composite of mortality and/or acute myocardial infarction (AMI), (3) major adverse cardiac events (MACE).Results Of 1526 articles screened, 6 were included, comprising 5.239 patients, and all utilised CRS derived from the History, ECG, Age, Risk-factor and Troponin (HEART) score. The summary of low-risk CRS diagnostic performance predicted all-cause mortality with a sensitivity of 93.2% (83.5–98.1) and NPV of 99.8% (99.5–99.9); mortality and/or AMI with a sensitivity of 91.8% (83.0–96.2) and an NPV of 97.3% (89.9–99.3); and MACE with a sensitivity of 92.8% (88.7–95.5) and an NPV of 97.2% (92.1–99.0). Lowering the CRS cut-off value for identifying low-risk patients increased sensitivity and NPV but decreased the proportion of patients classified as low risk.Conclusion In well-trained EMS systems, where prompt and accurate follow-up of low-risk patients is possible, HEART-derived CRS effectively identify patients with a very low risk of 30-day mortality and MACE. However, implementation in other healthcare systems requires additional validation, given the variations in healthcare structure, risk stratification processes and follow-up capabilities.",
  "authors": [
    {
      "affiliations": [
        "Department of Cardiology, Catharina Hospital, Eindhoven, Netherlands"
      ],
      "name": "Jesse Demandt"
    },
    {
      "affiliations": [
        "Faculty of Medical Sciences, University of Groningen, Groningen, Netherlands"
      ],
      "name": "Dennis Sagel"
    },
    {
      "affiliations": [
        "Cardiology, Radboud Universiteit Nijmegen, Nijmegen, Netherlands"
      ],
      "name": "Cyril Camaro"
    },
    {
      "affiliations": [
        "Department of Cardiology, Catharina Hospital, Eindhoven, Netherlands"
      ],
      "name": "Veerle A E van Hattem"
    },
    {
      "affiliations": [
        "Emergency Medicine, Wake Forest University, Winston-Salem, North Carolina, USA"
      ],
      "name": "Simon A Mahler"
    },
    {
      "affiliations": [
        "NHS Grampian, Aberdeen, UK",
        "University of Aberdeen, Aberdeen, UK"
      ],
      "name": "Jamie Cooper"
    },
    {
      "affiliations": [
        "Emergency Medical Services, Ambulance IJsselland, Zwolle, Netherlands"
      ],
      "name": "Rudolf Tolsma"
    },
    {
      "affiliations": [
        "Clinical Chemistry, Isala Hospital, Zwolle, Netherlands"
      ],
      "name": "Marion Fokkert"
    },
    {
      "affiliations": [
        "Department of IQ Health, Radboud University Medical Center, Nijmegen, Netherlands"
      ],
      "name": "Aysun Cetinyurek-Yavuz"
    },
    {
      "affiliations": [
        "Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA"
      ],
      "name": "Anna C Snavely"
    },
    {
      "affiliations": [
        "Scottish Ambulance Service, Edinburgh, UK"
      ],
      "name": "Lorna A A Donaldson"
    },
    {
      "affiliations": [
        "Cardiology, Utrecht University, Utrecht, Netherlands"
      ],
      "name": "Pim van der Harst"
    },
    {
      "affiliations": [
        "Cardiology, Maastricht University Medical Centre+, Maastricht, Netherlands",
        "Zuyderland Medical Centre Heerlen, Heerlen, Netherlands",
        "Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands"
      ],
      "name": "Arnoud van ’t Hof"
    },
    {
      "affiliations": [
        "Cardiology, Radboud Universiteit Nijmegen, Nijmegen, Netherlands"
      ],
      "name": "Niels van Royen"
    },
    {
      "affiliations": [
        "Department of Cardiology, Catharina Hospital, Eindhoven, Netherlands",
        "Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands"
      ],
      "name": "Marcel van ’t Veer"
    },
    {
      "affiliations": [
        "Department of Cardiology, Catharina Hospital, Eindhoven, Netherlands",
        "Netherlands Heart Network, Eindhoven, Netherlands"
      ],
      "name": "Pieter J Vlaar"
    }
  ],
  "title": "Prehospital risk stratification in suspected non-ST-segment elevation acute coronary syndrome with point-of-care troponin: an individual patient data meta-analysis",
  "uid": "7b87e90e-8fca-52c6-bcf2-1261c7e43f1b"
}