Prehospital risk stratification in patients with chest pain

Dennis Sagel*, Pieter Jan Vlaar, Radboud van Roosmalen, Ingmar Waardenburg, Wybe Nieuwland, Roelof Lettinga, Robert van Barneveld, Edward Jorna, Roelof Kijlstra, Carien van Well, Antoon Oomen, Louis Bartels, Rutger Anthonio, Vincent Hagens, Sjoerd Hofma, Youlan Gu, Derk Drenth, Ryanne Addink, Thea van Asselt, Peter van der MeerEric Lipsic, Luis Juarez Orozco, Pim van der Harst

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

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OBJECTIVES: The History, ECG, Age, Risk Factors and Troponin (HEART) Score is a decision support tool applied by physicians in the emergency department developed to risk stratify low-risk patients presenting with chest pain. We assessed the potential value of this tool in prehospital setting, when applied by emergency medical services (EMS), and derived and validated a tool adapted to the prehospital setting in order to determine if it could assist with decisions regarding conveyance to a hospital.

METHODS: In 2017, EMS personnel prospectively determined the HEART Score, including point-of-care (POC) troponin measurements, in patients presenting with chest pain, in the north of the Netherlands. The primary endpoint was a major adverse cardiac event (MACE), consisting of acute myocardial infarction or death, within 3 days. The components of the HEART Score were evaluated for their discriminatory value, cut-offs were calibrated for the prehospital setting and sex was substituted for cardiac risk factors to develop a prehospital HEART (preHEART) Score. This score was validated in an independent prospective cohort of 435 patients in 2018.

RESULTS: Among 1208 patients prospectively recruited in the first cohort, 123 patients (10.2%) developed a MACE. The HEART Score had a negative predictive value (NPV) of 98.4% (96.4-99.3), a positive predictive value (PPV) of 35.5% (31.8-39.3) and an area under the receiver operating characteristic curve (AUC) of 0.81 (0.78-0.85). The preHEART Score had an NPV of 99.3% (98.1-99.8), a PPV of 49.4% (42.0-56.9) and an AUC of 0.85 (0.82-0.88), outperforming the HEART Score or POC troponin measurements on their own. Similar results were found in a validation cohort.

CONCLUSIONS: The HEART Score can be used in the prehospital setting to assist with conveyance decisions and choice of hospitals; however, the preHEART Score outperforms both the HEART Score and single POC troponin measurements when applied by EMS personnel in the prehospital setting.

Original languageEnglish
Pages (from-to)814-819
Number of pages6
JournalEmergency medicine journal
Publication statusPublished - Nov-2021


  • Aged
  • Area Under Curve
  • Chest Pain/complications
  • Emergency Medical Services
  • Emergency Service, Hospital/organization & administration
  • Female
  • Humans
  • Male
  • Middle Aged
  • Netherlands/epidemiology
  • Prospective Studies
  • ROC Curve
  • Risk Assessment/methods
  • Risk Factors
  • Risk Management/methods

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