Researchers in The Netherlands have found that about 30% of presentations to emergency departments of patients with chest pain could be avoided if a highly sensitive troponin test is used in combination with other parameters by ambulance crews during pre-hospital triaging.
At present, about 95% of people with chest pains are transported by ambulance to emergency departments for further analysis, but only a minority have a serious cardiac condition. The study presented today (Friday) at the European Emergency Medicine Congress is the first to investigate the effect of combining the high-sensitive point-of-care troponin test and the HEART-score on hospital referrals for these patients.
Troponin tests measure the level of troponin proteins in the blood; these are raised when the heart muscle is damaged. Normally, these tests are carried out in the hospital laboratory when patients reach the emergency department. New, high-sensitive point-of-care troponin tests, such as the one developed by QuidelOrtho, that was used in this study, can provide on-the-spot results, often in less than 20 minutes, and have been shown to have the same accuracy as those analyzed in a central laboratory. They are starting to be used to make faster decisions about patients in the emergency department with chest pain.
The HEART-score is a scoring system that takes account of factors such as the patient's medical history, age, electrocardiogram (ECG) abnormalities, and risk factors like smoking, and categorizes them into being at low, medium or high risk of experiencing a heart problem. The HEART-score also incorporates a troponin test result. Since the better, high-sensitivity point-of-care troponin tests have become available, it is possible to calculate a HEART-score in the pre-hospital setting, allowing earlier risk stratification of patients with chest pain.
The study presented today was performed by the Rotterdam-Rijnmond ambulance service in The Netherlands and enrolled 1022 patients with chest pains between 2022 and 2025. In the 'before' phase of the study, 539 patients with acute chest pain were given the usual care before any decision about going to hospital was made. This consisted of an ambulance being dispatched to a patient with acute chest pain, the crew examining and assessing the patient and then deciding whether or not to transport the patient to the nearest emergency department or to a hospital where the patient was already known. If there were no indications of acute heart problems or another serious condition that required immediate treatment, the patient was left at home or referred to their general practitioner.
In the 'after' phase of the study, 483 patients were given the interventional treatment, which included the ambulance crew taking a blood sample when they reached the patient. This was analysed by the high-sensitive point-of-care troponin test while the crew carried out all the other usual examinations and assessments. After evaluating and recording the findings, the first four elements of the HEART-score (medical history, age, ECG and risk factors) were calculated. Once the troponin test was completed, the findings were added to the HEART-score to establish the patient's risk of experiencing a major adverse cardiovascular event (MACE), such as stroke, heart attack (myocardial infarction) or death as a result of problems with the heart or blood vessels.
Dr Barbra Backus told the congress: "If the HEART-score was low and the troponin test value was less than four nanograms per litre and there was no suspicion of another serious condition, such as a pulmonary embolism, pneumothorax or pancreatitis, then the patient was left at home or referred to their general practitioner. Clear instructions were provided to the patient to call emergency services again if the complaints didn't resolve, or deteriorated or recurred. When these criteria were not met, the patient was transported to an emergency department.
"We followed the patients for a minimum of one month, but for most patients we have over six months follow-up. During the 'before' phase, when the high-sensitive point-of-care troponin test was not used by the ambulance crews, 19 patients (3.5%) were left at home, whereas during the 'after' phase when the test was used, 165 patients (34.2%) were left at home. In other words, over a third of patients avoided going to an emergency department when they were assessed by the ambulance crews using the high-sensitive troponin test and HEART-score.
"Hospital referrals were reduced significantly, avoiding hospital overcrowding and unnecessary use of medical resources, while enabling more patients to avoid the stresses of the hospital environment. This is good for patients and good for hospitals."
With 86% of follow-up complete, the researchers found that 109 patients (12.4%) developed a MACE within 30 days: 15.0% before and 9.8% after implementation of the high-sensitive point-of-care troponin test. Of those left at home after implementation, only one out of 165 patients (0.6%) experienced a MACE within 30 days, compared to none out of 19 patients (0%) before the test's implementation.
Dr Backus said that this advanced, pre-hospital triage will be made mandatory in The Netherlands in 2027.
I think it is applicable to healthcare systems in many other countries too."
Dr. Barbra Backus, Rotterdam-Rijnmond ambulance service, The Netherlands
This study reflects the first real-world implementation of a high-sensitive point-of-care troponin test in a large urban ambulance service and enhances the generalizability of the findings for routine clinical practice. Limitations include the fact that not all patients were included in the study and there were more low-risk patients in the 'after' group; however, adjusting for this difference did not alter the results of the study in a meaningful way.
Dr Maša Sorić is a member of the EUSEM abstract selection committee. She is head of the emergency department at University Hospital Merkur, Zagreb, Croatia, and was not involved with the research. She said: "This study has the potential to refine the allocation of patients to emergency department while improving the quality and efficiency of pre-hospital emergency care. By enabling earlier rule-out of acute myocardial infarction in the pre-hospital setting, high-sensitivity point-of-care troponin testing may reduce unnecessary hospital transports and emergency department evaluations. Beyond emergency medical services, this approach could, with further validation, eventually be extended to other primary care settings, facilitating more efficient patient triage and resource utilization across the healthcare system."
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