Prehospital risk stratification in patients with chest pain.

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.

Boussignac continuous positive airway pressure for the management of acute cardiogenic pulmonary edema: prospective study with a retrospective control group.

BACKGROUND: Continuous positive airway pressure (CPAP) treatment for acute cardiogenic pulmonary edema can have important benefits in acute cardiac care. However, coronary care units are usually not equipped and their personnel not adequately trained for applying CPAP with mechanical ventilators. Therefore we investigated in the coronary care unit setting the feasibility and outcome of the simple Boussignac mask-CPAP (BCPAP) system that does not need a mechanical ventilator. METHODS: BCPAP was introduced in a coronary care unit where staff had no CPAP experience. All consecutive patients transported to our hospital with acute cardiogenic pulmonary edema, a respiratory rate > 25 breaths/min and a peripheral arterial oxygen saturation of < 95% while receiving oxygen, were included in a prospective BCPAP group that was compared with a historical control group that received conventional treatment with oxygen alone. RESULTS: During the 2-year prospective BCPAP study period 108 patients were admitted with acute cardiogenic pulmonary edema. Eighty-four of these patients (78%) were treated at the coronary care unit of which 66 (61%) were treated with BCPAP. During the control period 66 patients were admitted over a 1-year period of whom 31 (47%) needed respiratory support in the intensive care unit. BCPAP treatment was associated with a reduced hospital length of stay and fewer transfers to the intensive care unit for intubation and mechanical ventilation. Overall estimated savings of approximately euro 3,800 per patient were achieved with the BCPAP strategy compared to conventional treatment. CONCLUSION: At the coronary care unit, BCPAP was feasible, medically effective, and cost-effective in the treatment of acute cardiogenic pulmonary edema. Endpoints included mortality, coronary care unit and hospital length of stay, need of ventilatory support, and cost (savings).

Individual assessment of intensity-level for exercise training in patients with coronary artery disease is necessary.

BACKGROUND: Target intensity-level of exercise training in patients with coronary artery disease is adjusted usually by a target heart rate (THR). This THR is aimed to be at or nearby the anaerobic threshold (AT) and is calculated commonly from parameters of regular exercise training, instead of an actual measurement of AT and its related heart rate. Therefore, this study evaluated whether a calculation is reliable. METHODS: In 91 male patients (age 52+/-9 years) exercise capacity was measured after a recent (>4 weeks) coronary event. AT was compared with peak exercise capacity and heart rate at AT was compared with THR, using the Karvonen method. RESULTS: Mean AT (18.2 ml/min/kg, range 9.2-32.2) and mean peak V(O2) (24.5, range 10.9-43.9) were slightly decreased (respectively 0.83 and 0.79 of predicted). When related to peak exercise capacity, AT showed a large inter-individual variation. For example, heart rate at AT ranged from 0.55 to 0.96 of peak heart rate. As a result heart rate at AT varied considerably with THR. The mean THR, although significantly higher, correlated well with mean heart rate at AT (respectively, 109 and 105/min, P<0.01; r=0.86, P<0.001). However, in an important number of patients heart rate at AT was more than 10% below or above THR (respectively, 30 and 7%). CONCLUSION: In individual exercise prescription for cardiac rehabilitation the training level should be determined directly, and not indirectly by calculation from heart rate parameters of exercise testing.