Prehospital stratification in acute chest pain patient into high risk and low risk by emergency medical service: a prospective cohort study

Abstract

Objectives: To describe contemporary characteristics and diagnoses in prehospital patients with chest pain and to identify factors suitable for the early recognition of high-risk and low-risk conditions.

Design: Prospective observational cohort study.

Setting: Two centre study in a Swedish county emergency medical services (EMS) organisation.

Participants: Unselected inclusion of 2917 patients with chest pain contacting the EMS due to chest pain during 2018.

Primary outcome measures: Low-risk or high-risk condition, that is, occurrence of time-sensitive diagnosis on hospital discharge.

Results: Of included EMS missions, 68% concerned patients with a low-risk condition without medical need of acute hospital treatment in hindsight. Sixteen per cent concerned patients with a high-risk condition in need of rapid transport to hospital care. Numerous variables with significant association with low-risk or high-risk conditions were found. In total high-risk and low-risk prediction models shared six predictive variables of which ST-depression on ECG and age were most important. Previously known risk factors such as history of acute coronary syndrome, diabetes and hypertension had no predictive value in the multivariate analyses. Some aspects of the symptoms such as pain intensity, pain in the right arm and paleness did on the other hand appear to be helpful. The area under the curve (AUC) for prediction of low-risk candidates was 0.786 and for high-risk candidates 0.796. The addition of troponin in a subset increased the AUC to >0.8 for both.

Conclusions: A majority of patients with chest pain cared for by the EMS suffer from a low-risk condition and have no prognostic reason for acute hospital care given their diagnosis on hospital discharge. A smaller proportion has a high-risk condition and is in need of prompt specialist care. Building models with good accuracy for prehospital identification of these groups is possible. The use of risk stratification models could make a more personalised care possible with increased patient safety.

Keywords: accident & emergency medicine; cardiology; myocardial infarction.