Prehospital stratification and prioritisation of non-ST-segment elevation acute coronary syndrome patients (NSTEACS): the MARIACHI scale.
Non-ST-elevation myocardial infarction
Prehospital
Score
Unstable angina
Journal
Internal and emergency medicine
ISSN: 1970-9366
Titre abrégé: Intern Emerg Med
Pays: Italy
ID NLM: 101263418
Informations de publication
Date de publication:
08 2023
08 2023
Historique:
received:
18
01
2023
accepted:
11
04
2023
medline:
10
8
2023
pubmed:
3
5
2023
entrez:
2
5
2023
Statut:
ppublish
Résumé
The objective of this study was to develop and validate a risk scale (MARIACHI) for patients classified as non-ST-segment elevation acute coronary syndrome (NSTEACS) in a prehospital setting with the ability to identify patients at an increased risk of mortality at an early stage. A retrospective observational study conducted in Catalonia over two periods: 2015-2017 (development and internal validation cohort) and Aug 2018-Jan 2019 (external validation cohort). We included patients classified as prehospital NSTEACS, assisted by an advanced life support unit and requiring hospital admission. The primary outcome was in-hospital mortality. Cohorts were compared using logistic regression and a predictive model was created using bootstrapping techniques. The development and internal validation cohort included 519 patients. The model is composed of five variables associated with hospital mortality: age, systolic blood pressure, heart rate > 95 bpm, Killip-Kimball III-IV and ST depression ≥ 0.5 mm. The model showed good overall performance (Brier = 0.043) and consistency in discrimination (AUC 0.88, 95% CI 0.83-0.92) and calibration (slope = 0.91; 95% CI 0.89-0.93). We included 1316 patients for the external validation sample. There was no difference in discrimination (AUC 0.83, 95% CI 0.78-0.87; DeLong Test p = 0.071), but there was in calibration (p < 0.001), so it was recalibrated. The finally model obtained was stratified and scored into three groups according to the predicted risk of patient in-hospital mortality: low risk: < 1% (-8 to 0 points), moderate risk: 1-5% (+ 1 to + 5 points) and high risk: > 5% (6-12 points). The MARIACHI scale showed correct discrimination and calibration to predict high-risk NSTEACS. Identification of high-risk patients may help with treatment and low referral decisions at the prehospital level.
Identifiants
pubmed: 37131092
doi: 10.1007/s11739-023-03274-z
pii: 10.1007/s11739-023-03274-z
doi:
Types de publication
Observational Study
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
1317-1327Informations de copyright
© 2023. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).
Références
Alotaibi A, Alghamdi A, Reynard C, Body R (2021) Accuracy of emergency medical services (EMS) telephone triage in identifying acute coronary syndrome (ACS) for patients with chest pain: a systematic literature review. BMJ Open 11:e045815
pubmed: 34433592
pmcid: 8388270
doi: 10.1136/bmjopen-2020-045815
Kontos MC, de Lemos JA, Deitelzweig SB et al. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department. Journal of the American College of Cardiology. 2022. https//doi.org/ https://doi.org/10.1016/j.jacc.2022.08.750 .
Ibanez B, James S, Agewall S et al (2018) 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 39:119–177
pubmed: 28886621
doi: 10.1093/eurheartj/ehx393
Gulati M, Levy PD, Mukherjee D et al (2021) 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines [published correction appears in Circulation. Circulation 144:e368–e454
pubmed: 34709928
Collet JP, Thiele H, Barbato E, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation [published correction appears in Eur Heart J. 2021 May 14;42(19):1908] [published correction appears in Eur Heart J. 2021 May 14;42:1289–1367.
Pedersen CK, Stengaard C, Friesgaard K et al (2019) Chest pain in the ambulance; prevalence, causes and outcome - a retrospective cohort study. Scand J Trauma Resusc Emerg Med 27:84
pubmed: 31464622
pmcid: 6716930
doi: 10.1186/s13049-019-0659-6
Toušek P, Bauer D, Neuberg M et al (2022) Patient characteristics, treatment strategy, outcomes, and hospital costs of acute coronary syndrome: 3 years of data from a large high-volume centre in Central Europe. Eur Heart J Suppl 24(Suppl B):B3–B9
pubmed: 35370502
pmcid: 8971736
doi: 10.1093/eurheartjsupp/suac001
Demandt JPA, Zelis JM, Koks A et al (2022) Prehospital risk assessment in patients suspected of non-ST-segment elevation acute coronary syndrome: a systematic review and meta-analysis. BMJ Open 12:e057305
pubmed: 35383078
pmcid: 8984055
doi: 10.1136/bmjopen-2021-057305
Eagle KA, Lim MJ, Dabbous OH et al (2004) A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry. JAMA 291:2727–2733
pubmed: 15187054
doi: 10.1001/jama.291.22.2727
Slone SE, Barringhaus KG, Feldman B, Vismara V, Baker D (2021) Implementation of an accelerated discharge process following percutaneous coronary intervention for patients with non-ST elevation acute coronary syndromes. Eur J Cardiovasc Nurs 20:660–666
pubmed: 33709146
doi: 10.1093/eurjcn/zvaa029
Fox KA, Fitzgerald G, Puymirat E et al (2014) Should patients with acute coronary disease be stratified for management according to their risk? Derivation, external validation and outcomes using the updated GRACE risk score. BMJ Open 4:e004425
pubmed: 24561498
pmcid: 3931985
doi: 10.1136/bmjopen-2013-004425
Huynh T, Kouz S, Yan AT, et al. Canada Acute Coronary Syndrome Risk Score: a new risk score for early prognostication in acute coronary syndromes [published correction appears in Am Heart J. 2013;166(1):58–63.
Six AJ, Backus BE, Kelder JC (2008) Chest pain in the emergency room: value of the HEART score. Neth Heart J 16:191–196
pubmed: 18665203
pmcid: 2442661
doi: 10.1007/BF03086144
Backus BE, Six AJ, Kelder JC et al (2010) Chest pain in the emergency room: a multicenter validation of the HEART Score. Crit Pathw Cardiol 9:164–169
pubmed: 20802272
doi: 10.1097/HPC.0b013e3181ec36d8
Backus BE, Six AJ, Kelder JC et al (2013) A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol 168:2153–2158
pubmed: 23465250
doi: 10.1016/j.ijcard.2013.01.255
Tolsma RT, Fokkert MJ, van Dongen DN et al (2022) Referral decisions based on a pre-hospital HEART score in suspected non-ST-elevation acute coronary syndrome: final results of the FamouS Triage study. Eur Heart J Acute Cardiovasc Care 11:160–169
pubmed: 34849660
doi: 10.1093/ehjacc/zuab109
van Dongen DN, Fokkert MJ, Tolsma RT et al (2020) Accuracy of pre-hospital HEART score risk classification using point of care versus high sensitive troponin in suspected NSTE-ACS. Am J Emerg Med 38:1616–1620
pubmed: 31699426
doi: 10.1016/j.ajem.2019.158448
Stopyra JP, Harper WS, Higgins TJ et al (2018) Prehospital Modified HEART Score Predictive of 30-Day Adverse Cardiac Events. Prehosp Disaster Med 33:58–62
pubmed: 29316995
doi: 10.1017/S1049023X17007154
van Dongen DN, Tolsma RT, Fokkert MJ et al (2020) Referral decisions based on a prehospital HEART score in suspected non-ST-elevation acute coronary syndrome: design of the FamouS Triage 3 study. Future Cardiol 16(4):217–226
pubmed: 32551888
doi: 10.2217/fca-2019-0030
Collins GS, Reitsma JB, Altman DG, Moons KG (2015) Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): the TRIPOD statement. BMJ 350:g7594
pubmed: 25569120
doi: 10.1136/bmj.g7594
Recursos. SEM - Sistema d'Emergències Mèdiques. Accessed 13 Jan 2023. https://sem.gencat.cat/ca/emergencies-mediques/recursos/index.html#googtrans(ca/en )
Distribució territorial. SEM - Sistema d’Emergències Mèdiques. Accessed 13 Jan 2023. https://sem.gencat.cat/ca/emergencies-mediques/distribucioterritorial/index.html#googtrans(ca/en )
Roffi M, Patrono C, Collet JP et al (2016) 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: task force for the management of acute coronary syndromes in patients presenting without persistent st-segment elevation of the european society of cardiology (ESC). Eur Heart J 37:267–315
pubmed: 26320110
doi: 10.1093/eurheartj/ehv320
Gual N, Yuste Font A, Enfedaque Montes B, Blay Pueyo C, Martín Álvarez R, Inzitari M (2017) Profile and evolution of chronic complex patients in a subacute unit. Aten Primaria 49(9):510–517. https://doi.org/10.1016/j.aprim.2016.11.010
doi: 10.1016/j.aprim.2016.11.010
pubmed: 28292582
pmcid: 6876035
Conjunt mínim bàsic de dades (CMBD). Barcelona (Spain): CatSalut. Servei Català de la Salut, 2020. Available: https:// https://catsalut.gencat.cat/ca/proveidors-professionals/registres-catalegs/registres/cmbd/index.html#googtrans(ca/en )
Harrell FE Jr, Lee KL, Mark DB (1996) Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Stat Med 15:361–387
pubmed: 8668867
doi: 10.1002/(SICI)1097-0258(19960229)15:4<361::AID-SIM168>3.0.CO;2-4
Selig K, Shaw P, Ankerst D (2020) Bayesian information criterion approximations to Bayes factors for univariate and multivariate logistic regression models. Int J Biostat 17:241–266
pubmed: 33119543
doi: 10.1515/ijb-2020-0045
Steyerberg EW, Harrell FE Jr, Borsboom GJ, Eijkemans MJ, Vergouwe Y, Habbema JD (2001) Internal validation of predictive models: efficiency of some procedures for logistic regression analysis. J Clin Epidemiol 54:774–781
pubmed: 11470385
doi: 10.1016/S0895-4356(01)00341-9
Núñez E, Steyerberg EW, Núñez J (2011) Estrategias para la elaboración de modelos estadísticos de regresión [Regression modeling strategies]. Rev Esp Cardiol 64:501–507
pubmed: 21531065
doi: 10.1016/j.recesp.2011.01.019
Álvarez Álvarez B, Abou Jokh Casas C, Cordero A, et al. Early revascularization and long-term mortality in high-risk patients with non-ST-elevation myocardial infarction. The CARDIOCHUS-HUSJ registry. Rev Esp Cardiol (Engl Ed). 2020;73:35–42.
Bueno H, Rossello X, Pocock SJ et al (2019) In-hospital coronary revascularization rates and post-discharge mortality risk in non-st-segment elevation acute coronary syndrome. J Am Coll Cardiol 74:1454–1461
pubmed: 31514947
doi: 10.1016/j.jacc.2019.06.068
Reina A, Colmenero M, García C et al (2014) Health care outcome differences for patients first attended for ST-segment elevation myocardial infarction in Andalusian hospitals with or without a cardiac catheterization laboratory. Emergencias 26:101–108
Ruiz-Nodar JM, Cequier A, Lozano T et al (2010) Influence of hospital type on treatment and prognosis in patients with non-ST elevation acute coronary syndrome. Rev Esp Cardiol 63:390–399
pubmed: 20334804
doi: 10.1016/S0300-8932(10)70059-2
Ferreira AS, Costa J, Braga CG, Marques J (2019) Impact on mortality of direct admission versus interhospital transfer in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Rev Port Cardiol (Engl Ed) 38:621–631
pubmed: 31784297
doi: 10.1016/j.repc.2019.02.005
Roe MT, Chen AY, Delong ER et al (2008) Patterns of transfer for patients with non-ST-segment elevation acute coronary syndrome from community to tertiary care hospitals. Am Heart J 156:185–192
pubmed: 18585515
doi: 10.1016/j.ahj.2008.01.033
Lapostolle F, Loyeau A, Beggaz Y et al (2021) Effect of age, gender, and time of day on pain-to-call times in patients with acute ST-segment elevation myocardial infarction: the CLOC’AGE study. Emergencias 33:181–186
pubmed: 33978331
Aboal J, Ramos R, Loma-Osorio P et al (2021) Time from electrocardiographic diagnosis of ST-elevation myocardial infarction to guidewire crossing in patients transferred to a hospital for primary angioplasty: factors associated with delay. Emergencias 33:195–202
pubmed: 33978333
Shi O, Khan AM, Rezai MR et al (2018) Factors associated with door-in to door-out delays among ST-segment elevation myocardial infarction (STEMI) patients transferred for primary percutaneous coronary intervention: a population-based cohort study in Ontario. Canada BMC Cardiovasc Disord 18:204
pubmed: 30373536
doi: 10.1186/s12872-018-0940-z
Soto-Cámara R, González-Bernal J, Aguilar-Parra JM, Trigueros R, López-Liria R, González-Santos J. Factors related to prehospital time in caring for patients with stroke. Análisis de los factores relacionados con el tiempo prehospitalario en la atención al ictus. Emergencias. 2021;33:454–463.
Coiro S, Cavallini C (2020) Impact of mobile intensive care units on STEMI delays and outcomes-Is it simply a matter of time? Eur J Intern Med 73:27–29
pubmed: 32035701
doi: 10.1016/j.ejim.2020.01.022
van Meerten KF, Haan RMA, Dekker IMC, van Zweden HJJ, van Zwet EW, Backus BE (2021) The interobserver agreement of the HEART-score, a multicentre prospective study. Eur J Emerg Med 28:111–118
pubmed: 33136732
doi: 10.1097/MEJ.0000000000000758
Wu WK, Yiadom MY, Collins SP, Self WH, Monahan K. Documentation of HEART score discordance between emergency physician and cardiologist evaluations of ED patients with chest pain. Am J Emerg Med. 2017;35:132–135.
Moumneh T, Penaloza A, Cismas A et al (2021) Evaluation of HEAR score to rule-out major adverse cardiac events without troponin test in patients presenting to the emergency department with chest pain. Eur J Emerg Med 28:292–298
pubmed: 34187993
doi: 10.1097/MEJ.0000000000000791
Khaleghi Rad M, Pirmoradi MM, Doosti-Irani A, Thiruganasambandamoorthy V, Mirfazaelian H (2022) The performance of HEAR score for identification of low-risk chest pain: a systematic review and meta-analysis. Eur J Emerg Med 29:173–187
pubmed: 35446265
doi: 10.1097/MEJ.0000000000000921
Koh HP, Md Redzuan A, Mohd Saffian S, Hassan H, R Nagarajah J, Ross NT. Mortality outcomes and predictors of failed thrombolysis following STEMI thrombolysis in a non-PCI capable tertiary hospital: a 5-year analysis. Intern Emerg Med. 2023;17:1–12.
Del Buono MG, Montone RA, Rinaldi R, et al. Clinical predictors and prognostic role of high Killip class in patients with a first episode of anterior ST-segment elevation acute myocardial infarction. J Cardiovasc Med (Hagerstown). 2021;22:530-538
Kaul P, Fu Y, Chang WC, et al. Prognostic value of ST segment depression in acute coronary syndromes: insights from PARAGON-A applied to GUSTO-IIb. PARAGON-A and GUSTO IIb Investigators. Platelet IIb/IIIa Antagonism for the Reduction of Acute Global Organization Network. J Am Coll Cardiol. 2001;38:64–71.
Brilakis ES, Mavrogiorgos NC, Kopecky SL et al (2002) Usefulness of QRS duration in the absence of bundle branch block as an early predictor of survival in non-ST elevation acute myocardial infarction. Am J Cardiol 89:1013–1018
pubmed: 11988187
doi: 10.1016/S0002-9149(02)02267-1
Jiménez-Candil J, González IC, González Matas JM et al (2007) Short- and long-term prognostic value of the corrected QT interval in the non-ST-elevation acute coronary syndrome. J Electrocardiol 40:180–187
pubmed: 17254595
doi: 10.1016/j.jelectrocard.2006.10.006
Rasmussen MB, Stengaard C, Sørensen JT et al (2019) Comparison of acute versus subacute coronary angiography in patients with non-st-elevation myocardial infarction (from the NONSTEMI Trial). Am J Cardiol 124:825–832
pubmed: 31324357
doi: 10.1016/j.amjcard.2019.06.007
Alghamdi A, Alotaibi A, Alharbi M, Reynard C, Body R (2020) Diagnostic Performance of Prehospital Point-of-Care Troponin Tests to Rule Out Acute Myocardial Infarction: A Systematic Review. Prehosp Disaster Med 35:567–573
pubmed: 32641173
doi: 10.1017/S1049023X20000850
Bhatt DL, Lopes RD, Harrington RA (2022) Diagnosis and Treatment of Acute Coronary Syndromes: A Review. JAMA 327:662–675
pubmed: 35166796
doi: 10.1001/jama.2022.0358
Abu-Assi E, García-Acuña JM, Peña-Gil C, González-Juanatey JR (2010) Validation of the GRACE risk score for predicting death within 6 months of follow-up in a contemporary cohort of patients with acute coronary syndrome. Rev Esp Cardiol 63:640–648
pubmed: 20515621
doi: 10.1016/S0300-8932(10)70156-1
Sanz-Girgas E, Peiró ÓM, Bonet G et al (2021) A simple combination of biomarkers for risk stratification in octogenarians with acute myocardial infarction. Rev Cardiovasc Med 22(4):1711–1720
pubmed: 34957814
doi: 10.31083/j.rcm2204179
Falco L, Fabris E, Gregorio C et al (2022) Early prognostic stratification and identification of irreversibly shocked patients despite primary percutaneous coronary intervention. J Cardiovasc Med (Hagerstown) 23(4):247–253
pubmed: 34907143
doi: 10.2459/JCM.0000000000001282