Not every patient with chest pain needs to be referred to the hospital. Pre-hospital troponin measurement in low-risk patients significantly reduces healthcare costs while incidence of a major adverse cardiac event was low in both the pre-hospital strategy and the standard strategy. This was shown by research led by Radboud university medical center.
In The Netherlands, ambulances transport around 200,000 people with chest pain to Emergency Departments (ED) every year. However, up to 90 percent of these people don’t have an acute coronary syndrome. Cardiologists at Radboud university medical center studied the possibility of initially examining these patients at home, and only transporting them to the hospital in case of a high risk of acute coronary syndrome (elevated troponin). The results show that hospital visits are often unnecessary and costs-saving.
Low risk of acute coronary syndrome
Nearly 900 people with chest pain participated in the study. Ambulance professionals assessed the risk of an acute coronary syndrome based on the HEAR-score, including history, electrocardiogram [ECG], age and risk factors. Patients with a high risk for an acute coronary syndrome were directly transported to the hospital. In patients with a low risk HEAR score, ambulance paramedics performed a pre-hospital troponin measurement. The protein troponin is released when the heart is damaged, and is an indication of a heart attack.
Were troponin levels high? Then the patient went straight to the hospital. But if the troponin level was low, then the patient remained at home, provided with further instructions such as contact with the general practitioner. All patients were followed up to 30 days after the event. The researchers investigated whether a major adverse cardiac event (MACE) occurred during that period.
The chance of MACE was very small. In the patient group that stayed at home with a low troponin level, a major heart problem occurred in 0.5% of cases, in the group that went to the hospital with a low troponin level this was 1.0%. Physician-researcher Joris Aarts: 'Patients with a low risk of myocardial infarction can generally stay at home safely. This is good news, because an emergency ambulance ride and hospitalisation are major events with high costs. Now we know that it is often unnecessary.'
Reducing healthcare costs
In addition, this new analysis at the patient's home reduces healthcare costs. The researchers calculated that it reduces more than 600 euros per patient if they stay out of the hospital. Cardiologist and lead researcher Cyril Camaro: ‘If we introduce this throughout the Netherlands, it will save up to 48 million euros on an annual basis. The Dutch Integral Healthcare Agreement insists on more efficient care. We all have a role in this.’
He also emphasizes better deployment of ambulances: ‘We are deploying ambulance staff more intelligently. Moreover, despite the pre-hospital troponin measurement, they are more quickly available for a new patient because they don't have to transport every patient to the ED.’ Finally, this approach can also be a solution in the growing problem of overcrowding Emergency Departments. Camaro: ‘In this study, we collaborated with many colleagues. We had to, because a possible change in policy affects everyone: the patient, the ambulance staff, general practitioners, emergency physicians and cardiologists. That's why we have to do it together.’
For the next years Camaro is focused to put this topic on the national agenda. T. Recently a national consortium meeting was initiated to discuss this important theme. Hopefully more collaboration and (randomized) studies on pre-hospital rule out strategies will follow and in the end to implement the best pre hospital strategy for all our chest pain patients.
About the publication
This publication appeared online in the European Heart Journal: Rule-out of non-ST-segment elevation acute coronary syndrome by a single, pre-hospital troponin measurement: a randomized trial - Cyril Camaro, Goaris W.A. Aarts, Eddy M.M. Adang, Roger van Hout, Gijs Brok, Anouk Hoare, Laura Rodwell, Frank de Pooter, Walter de Wit, Gilbert E. Cramer, Roland R.J. van Kimmenade, Peter Damman, Eva Ouwendijk, Martijn Rutten, Erwin Zegers, Robert-Jan M. van Geuns, Marc E.R. Gomes, Niels van Royen on behalf of the ARTICA Investigators.
The ARTICA trial is funded by ZonMw and Betaalbaar Beter. ARTICA is an investigator-initiated, multicentre, open-label, randomised controlled trial in five ambulance regions in the Netherlands, with a total of 112 ambulances and 552 ambulance paramedics, including Ambulance Care Gelderland-Midden and Gelderland-Zuid, White Cross Zeeland and North and East Gelderland, ZorgSaam Zeeuws-Vlaanderen and RAV Brabant-Midden-West-Noord.