pre-hospital rule-out of acute coronary syndrome

Conditions: Acute Coronary Syndrome

Summary: patients with chest pain suspected for non st-segment elevation acute coronary syndrome (nste-acs) are routinely transferred to the emergency department (ed). a point-of-care (poc) troponin measurement might enable ambulance paramedics to identify low-risk patients in whom ed evaluation is not necessary. the artica trial aims to assess the healthcare cost reduction and safety of a pre-hospital rule-out strategy using a single poc troponin measurement.

patients with chest pain suspected of a nste-acs are screened by ambulance paramedics. the hear score (heart score without the troponin component) is assessed and patients with a hear score of ≤3 are included. the patients are randomised to 1) pre-hospital rule-out with poc troponin measurement (intervention group) and 2) direct transfer to the ed (standard care group). primary outcome is healthcare costs after 30 days.

Eligibility criteria:
inclusion criteria: * age at least 18 years; male ánd female * all out-of-hospital patients with chest pain or symptoms suggestive of acs initially visited by an ambulance with an indication for transfer to a hospital to evaluate and rule out acs * symptom duration for at least two hours * modified hear(t) score less or equal than 3 * a point of care troponin below the upper reference limit (for patients stratified to pre-hospital management by the general practitioner) * the patient has been informed of the nature of the study, agrees to its provisions and has provided written informed consent. exclusion criteria: * electrocardiographic st-segment elevation * patients presenting an obvious non-cardiac cause for the chest complaints who need evaluation at an emergency department, e.g. trauma, pneumothorax, sepsis, etc. * patients in comatose state, defined as an glascgow coma scale (gcs) \<8 * patients with known cognitive impairment * pregnancy or intention to become pregnant during the course of the study * patients presenting cardiogenic shock, defined as: systolic blood pressure \ 100 beats per minute and peripheral oxygen saturation \<90% (without oxygen administration) * patients presenting with syncope * patients presenting with signs of heart failure * patients presenting with heart rhythm disorders and second or third degree atrioventricular block * patients with known end-stage renal disease (dialysis and/or glomular filtration rate (gfr) \< 30 ml/min) * patients without a pre-hospital 12-lead ecg performed or available * patients suspicious of aortic dissection or pulmonary embolism * patients with confirmed acute myocardial infarction, percutaneous coronary intervention or coronary artery bypass grafting \<30 days prior to inclusion * communication issues with patient/language barrier * decision of a present general practitioner to evaluate the patient at the emergency department (ed) * decision of the consultant cardiologist to evaluate patient at the er irrespective of heart score * any significant medical or mental condition, which in the investigators opinion may interfere with the patients optimal participation in the study

Keywords: point-of-care troponin heart score acute coronary syndrome myocardial infarction