New ambulance triage method could reduce emergency visits for chest pain
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Researchers in the Netherlands have found that about 30% of emergency department visits by patients with chest pain could be avoided if ambulance crews used a high-sensitivity troponin test alongside other measures during prehospital triage.
At present, about 95% of people with chest pain are transported by ambulance to emergency departments for further evaluation, but only a minority have a serious cardiac condition. The study presented at the European Emergency Medicine Congress is the first to investigate how combining a high-sensitivity point-of-care troponin test with the HEART score affects hospital referrals for these patients.
Troponin tests measure the level of troponin proteins in the blood, which rises when the heart muscle is damaged. Normally, these tests are carried out in a hospital laboratory after patients reach the emergency department.
New high-sensitivity point-of-care troponin tests, such as the QuidelOrtho test used in this study, can provide on-the-spot results, often in less than 20 minutes. They have been shown to be as accurate as tests analyzed in a central laboratory and are starting to be used to make faster decisions about emergency department patients with chest pain.
The HEART score takes into account factors such as a patient's medical history, age, electrocardiogram (ECG) abnormalities and risk factors like smoking. It categorizes patients as being at low, medium or high risk of a heart problem and incorporates a troponin test result.
With high-sensitivity point-of-care troponin tests now available, it is possible to calculate a HEART score before a patient reaches the hospital, allowing earlier risk assessment of patients with chest pain.
The study was conducted by the Rotterdam-Rijnmond ambulance service in the Netherlands and enrolled 1,022 patients with chest pain between 2022 and 2025. In the "before" phase, 539 patients with acute chest pain received usual care before a decision was made about whether to take them to a hospital.
Under usual care, an ambulance crew examined and assessed each patient, then decided whether 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 an acute heart problem or another serious condition requiring immediate treatment, the patient was left at home or referred to their general practitioner.
In the "after" phase, 483 patients received the intervention. When ambulance crews reached a patient, they took a blood sample and analyzed it using the high-sensitivity point-of-care troponin test while carrying out their usual examinations and assessments. They then calculated the first four elements of the HEART score: medical history, age, ECG and risk factors.
Once the troponin test was complete, they added its result to the score to establish the patient's risk of a major adverse cardiovascular event (MACE), such as a stroke, heart attack (myocardial infarction) or death resulting from a problem 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 liter 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, 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 of follow-up. During the 'before' phase, when the high-sensitivity point-of-care troponin test was not used by ambulance crews, 19 patients (3.5%) were left at home. 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 ambulance crews assessed them using the high-sensitivity 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%) had a MACE within 30 days: 15.0% before and 9.8% after implementation of the high-sensitivity point-of-care troponin test. Of those left at home after implementation, one of 165 patients (0.6%) experienced a MACE within 30 days, compared with none of the 19 patients (0%) left at home before implementation.
Backus said this advanced prehospital triage will be mandatory in the Netherlands in 2027. "I think it is applicable to health care systems in many other countries too," she said.
The study reflects the first real-world implementation of a high-sensitivity point-of-care troponin test in a large urban ambulance service and makes the findings more generalizable to routine clinical practice. Limitations include the fact that not all patients were included in the study and that there were more low-risk patients in the "after" group. However, adjusting for that difference did not meaningfully alter the results.
Dr. Maša Sorić, a member of the EUSEM abstract selection committee, is head of the emergency department at University Hospital Merkur in Zagreb, Croatia. She was not involved in the research.
"This study has the potential to refine the allocation of patients to the emergency department while improving the quality and efficiency of prehospital emergency care," she said.
"By enabling earlier rule-out of acute myocardial infarction in the prehospital 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 health care system."
More information
Barbra Backus et al, Implementation of high-sensitive point-of-care troponin in the prehospital setting, a before-after trial, preliminary results
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