Ulster University



TITLE: Systematic review of clinical decision support systems for pre-hospital acute coronary syndrome identification.AuthorsCharles Richard Knoery (MHChB)*1,2Janet Heaton (PhD)*1 Rob Polson (MSc)*3Raymond Bond (PhD)*4Aleeha Iftikhar (MSc)*4Khaled Rjoob (MSc)*4Victoria McGilligan (PhD)*5Aaron Peace (PhD)*5,6Stephen James Leslie (PhD)*1,2 Affiliations 1. Division of Rural Health and Wellbeing, University of the Highlands and Islands, Centre for Health Science, Old Perth Road, Inverness, UK, IV2 3JH2. Cardiac Unit, NHS Highland, Inverness, UK, IV2 3BW3. Highland Health Sciences Library, University of the Highlands and Islands, Centre for Health Science, Old Perth Road, Inverness, UK, IV2 3JH4. Ulster University, Jordanstown Campus, Shore Road, Newtownabbey, Northern Ireland, UK, BT37 0QB5.Centre for Personalised Medicine, Ulster University, Londonderry BT47 6SB, Northern Ireland, UK6. Cardiac Department, Altnagelvin Hospital, Northern Ireland, UK, BT47 6SBAuthor for correspondence: Charles Knoery, Division of Rural Health and Wellbeing, University of the Highlands and Islands, Centre for Health Science, Old Perth Road, Inverness, UK, IV2 3JHEmail: Charles.knoery@uhi.ac.ukCONFLICTS OF INTEREST: None to declare.CONTRIBUTORS: All authors contributed to the writing and reviewing of the manuscript prior to submission. The views and opinions expressed in this document do not necessarily reflect those of the European Commission or the Special EU Programmes Body (SEUPB).SHORT TITLE: Clinical decision support system for ACS.FUNDING: A project supported by the European Union’s INTERREG VA Programme, managed by the Special EU Programmes Body (SEUPB). The funders of this project had no input in designing, implementation or writing of this review. Keywords: Acute coronary syndrome, algorithm, clinical decision support systems, diagnosis, emergency medical services.Word Count: 3,617Prospero registration number: 116600Type of paper: Systematic reviewABSTRACTObjectiveTimely pre-hospital diagnosis and treatment of acute coronary syndrome (ACS) are required to achieve optimal outcomes. Clinical decision support systems (CDSS) are platforms designed to integrate multiple data and can aid with management decisions in the pre-hospital environment. The review aim was to describe the accuracy of CDSS and individual components in the pre-hospital ACS management. MethodsThis systematic review examined the current literature regarding the accuracy of CDSS for ACS in the pre-hospital setting, the influence of computer-aided decision making and of four components: electrocardiogram, biomarkers, patient history and examination findings. The impact of these components on sensitivity, specificity, positive and negative predictive values was assessed. ResultsA total of 11,439 articles were identified from a search of databases, of which 199 were screened against the eligibility criteria. Eight studies were found to meet the eligibility and quality criteria. There was marked heterogeneity between studies which precluded formal meta-analysis. However, individual components analysis found that patient history led to significant improvement in the sensitivity and negative predictive values. CDSS which incorporated all four components tended to show higher sensitivities and negative predictive values. CDSS incorporating computer-aided electrocardiogram diagnosis showed higher specificities and positive predictive values. ConclusionsAlthough heterogeneity precluded meta-analysis, this review emphasises the potential of ACS CDSS in pre-hospital environments that incorporate patient history in addition to integration of multiple components. The higher sensitivity of certain components, along with higher specificity of computer-aided decision-making, highlights the opportunity for developing an integrated algorithm with computer-aided decision support. INTRODUCTIONDespite a decline in coronary heart disease deaths by more than 50% between 1961 and 2016, coronary heart disease is still a leading cause of mortality in the United Kingdom ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"TXAVdsZ9","properties":{"formattedCitation":"\\super 1\\nosupersub{}","plainCitation":"1","noteIndex":0},"citationItems":[{"id":340,"uris":[""],"uri":[""],"itemData":{"id":340,"type":"article","language":"English","publisher":"BHF","title":"Cardiovascular Disease UK Statistics Factsheet","URL":"","author":[{"family":"British Heart Foundation","given":""}],"accessed":{"date-parts":[["2018",11,5]]},"issued":{"date-parts":[["2018",11]]}}}],"schema":""} 1. In Scotland, acute coronary syndrome (ACS) is a major cause of mortality with 6,697 deaths in 2016 ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"dkLktdE6","properties":{"formattedCitation":"\\super 2\\nosupersub{}","plainCitation":"2","noteIndex":0},"citationItems":[{"id":324,"uris":[""],"uri":[""],"itemData":{"id":324,"type":"article","title":"Scottish Heart Disease Statistics. Year Ending 31 March 2017","URL":"","author":[{"family":"Information Services Division","given":""}],"accessed":{"date-parts":[["2018",10,26]]}}}],"schema":""} 2. ST elevation myocardial infarction (STEMI) is the most acutely critical subtype of ACS with highest 30-day mortality ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"MgDa9cmQ","properties":{"formattedCitation":"\\super 3\\uc0\\u8211{}5\\nosupersub{}","plainCitation":"3–5","noteIndex":0},"citationItems":[{"id":326,"uris":[""],"uri":[""],"itemData":{"id":326,"type":"book","collection-number":"148","event-place":"Edinburgh","publisher":"SIGN","publisher-place":"Edinburgh","title":"Acute Coronary Syndrome","URL":"","author":[{"family":"Scottish Intercollegiate Guidelines Network (SIGN)","given":""}],"accessed":{"date-parts":[["2018",10,26]]},"issued":{"date-parts":[["2016",4]]}}},{"id":304,"uris":[""],"uri":[""],"itemData":{"id":304,"type":"report","language":"eng","number":"Clinical guidance 167","title":"Myocardial infarction with ST-segment elevation: acute management: Guidance and guidelines","title-short":"Myocardial infarction with ST-segment elevation","URL":"","author":[{"family":"National Institute for Health and Care Excellance","given":""}],"accessed":{"date-parts":[["2018",10,10]]},"issued":{"date-parts":[["2013"]]}}},{"id":425,"uris":[""],"uri":[""],"itemData":{"id":425,"type":"article-journal","abstract":"The aim of this study was to describe differences in the characteristics and short- and long-term prognoses of patients with first acute myocardial infarction (MI) according to the presence of ST-segment elevation or non-ST-segment elevation. From 2001 and 2003, 2,048 patients with first MI were consecutively admitted to 6 participating Spanish hospitals and categorized as having ST-segment elevation MI (STEMI), non-ST-segment elevation MI (NSTEMI), or unclassified MI (pacemaker or left bundle branch block) according to electrocardiographic results at admission. The proportions of female gender, hypercholesterolemia, hypertension, and diabetes were higher among NSTEMI patients than in the STEMI group. NSTEMI 28-day case fatality was lower (2.99% vs 5.26%, p = 0.02). On multivariate analysis, the odds ratio of 28-day case fatality was 2.23 for STEMI patients compared to NSTEMI patients (95% confidence interval 1.29 to 3.83, p = 0.004). The multivariate adjusted 7-year mortality for 28-day survivors was higher in NSTEMI than in STEMI patients (hazard ratio 1.31, 95% confidence interval 1.02 to 1.68, p = 0.035). However, patients with unclassified MI presented the highest short- and long-term mortality (11.8% and 35.4%, respectively). The excess of short-term mortality in unclassified and STEMI patients was mainly observed in those patients not treated with revascularization procedures. In conclusion, patients with first NSTEMI were older and showed a higher proportion of previous coronary risk factors than STEMI patients. NSTEMI patients had lower 28-day case fatality but a worse 7-year mortality rate than STEMI patients. Unclassified MI presented the worst short- and long-term prognosis. These results support the invasive management of patients with acute coronary syndromes to reduce short-term case fatality.","container-title":"The American Journal of Cardiology","DOI":"10.1016/j.amjcard.2011.06.003","ISSN":"1879-1913","issue":"8","journalAbbreviation":"Am. J. Cardiol.","language":"eng","note":"PMID: 21791326","page":"1061-1067","source":"PubMed","title":"Long-term prognosis of first myocardial infarction according to the electrocardiographic pattern (ST elevation myocardial infarction, non-ST elevation myocardial infarction and non-classified myocardial infarction) and revascularization procedures","volume":"108","author":[{"family":"García-García","given":"Cosme"},{"family":"Subirana","given":"Isaac"},{"family":"Sala","given":"Joan"},{"family":"Bruguera","given":"Jordi"},{"family":"Sanz","given":"Gines"},{"family":"Valle","given":"Vicente"},{"family":"Arós","given":"Fernando"},{"family":"Fiol","given":"Miquel"},{"family":"Molina","given":"Lluis"},{"family":"Serra","given":"Jordi"},{"family":"Marrugat","given":"Jaume"},{"family":"Elosua","given":"Roberto"}],"issued":{"date-parts":[["2011",10,15]]}}}],"schema":""} 3–5. Time is critical for STEMI management as mortality increases with treatment delays ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"4Zj4VmQY","properties":{"formattedCitation":"\\super 4,6\\nosupersub{}","plainCitation":"4,6","noteIndex":0},"citationItems":[{"id":304,"uris":[""],"uri":[""],"itemData":{"id":304,"type":"report","language":"eng","number":"Clinical guidance 167","title":"Myocardial infarction with ST-segment elevation: acute management: Guidance and guidelines","title-short":"Myocardial infarction with ST-segment elevation","URL":"","author":[{"family":"National Institute for Health and Care Excellance","given":""}],"accessed":{"date-parts":[["2018",10,10]]},"issued":{"date-parts":[["2013"]]}}},{"id":8,"uris":[""],"uri":[""],"itemData":{"id":8,"type":"article-journal","abstract":"BACKGROUND: Although the relationship between mortality and time delay to treatment has been demonstrated in patients with acute ST-segment elevation myocardial infarction (STEMI) treated by thrombolysis, the impact of time delay on prognosis in patients undergoing primary angioplasty has yet to be clarified. The aim of this report was to address the relationship between time to treatment and mortality as a continuous function and to estimate the risk of mortality for each 30-minute delay.\nMETHODS AND RESULTS: The study population consisted of 1791 patients with STEMI treated by primary angioplasty. The relationship between ischemic time and 1-year mortality was assessed as a continuous function and plotted with a quadratic regression model. The Cox proportional hazards regression model was used to calculate relative risks (for each 30 minutes of delay), adjusted for baseline characteristics related to ischemic time. Variables related to time to treatment were age >70 years (P<0.0001), female gender (P=0.004), presence of diabetes mellitus (P=0.002), and previous revascularization (P=0.035). Patients with successful reperfusion had a significantly shorter ischemic time (P=0.006). A total of 103 patients (5.8%) had died at 1-year follow-up. After adjustment for age, gender, diabetes, and previous revascularization, each 30 minutes of delay was associated with a relative risk for 1-year mortality of 1.075 (95% CI 1.008 to 1.15; P=0.041).\nCONCLUSIONS: These results suggest that every minute of delay in primary angioplasty for STEMI affects 1-year mortality, even after adjustment for baseline characteristics. Therefore, all efforts should be made to shorten the total ischemic time, not only for thrombolytic therapy but also for primary angioplasty.","container-title":"Circulation","DOI":"10.1161/01.CIR.0000121424.76486.20","ISSN":"1524-4539","issue":"10","journalAbbreviation":"Circulation","language":"eng","note":"PMID: 15007008","page":"1223-1225","source":"PubMed","title":"Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts","title-short":"Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction","volume":"109","author":[{"family":"De Luca","given":"Giuseppe"},{"family":"Suryapranata","given":"Harry"},{"family":"Ottervanger","given":"Jan Paul"},{"family":"Antman","given":"Elliott M."}],"issued":{"date-parts":[["2004",3,16]]}}}],"schema":""} 4,6. Pre-hospital STEMI identification has been shown to reduce treatment delays and improve mortality ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"GmkLXZRK","properties":{"formattedCitation":"\\super 7,8\\nosupersub{}","plainCitation":"7,8","noteIndex":0},"citationItems":[{"id":328,"uris":[""],"uri":[""],"itemData":{"id":328,"type":"article-journal","container-title":"Circulation","DOI":"10.1161/CIRCULATIONAHA.108.190402","ISSN":"1524-4539","issue":"10","journalAbbreviation":"Circulation","language":"eng","note":"PMID: 18703464","page":"1066-1079","source":"PubMed","title":"Implementation and integration of prehospital ECGs into systems of care for acute coronary syndrome: a scientific statement from the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee, Council on Cardiovascular Nursing, and Council on Clinical Cardiology","title-short":"Implementation and integration of prehospital ECGs into systems of care for acute coronary syndrome","volume":"118","author":[{"family":"Ting","given":"Henry H."},{"family":"Krumholz","given":"Harlan M."},{"family":"Bradley","given":"Elizabeth H."},{"family":"Cone","given":"David C."},{"family":"Curtis","given":"Jeptha P."},{"family":"Drew","given":"Barbara J."},{"family":"Field","given":"John M."},{"family":"French","given":"William J."},{"family":"Gibler","given":"W. Brian"},{"family":"Goff","given":"David C."},{"family":"Jacobs","given":"Alice K."},{"family":"Nallamothu","given":"Brahmajee K."},{"family":"O'Connor","given":"Robert E."},{"family":"Schuur","given":"Jeremiah D."},{"literal":"American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee"},{"literal":"American Heart Association Council on Cardiovascular Nursing"},{"literal":"American Heart Association Council on Clinical Cardiology"}],"issued":{"date-parts":[["2008",9,2]]}}},{"id":643,"uris":[""],"uri":[""],"itemData":{"id":643,"type":"article-journal","abstract":"STUDY OBJECTIVE: We sought to evaluate quantitatively the evidence on the diagnostic performance of out-of-hospital ECG for the diagnosis of acute cardiac ischemia (ACI) and acute myocardial infarction (AMI) and the clinical effect of out-of-hospital thrombolysis.\nMETHODS: We conducted a systematic review and meta-analysis of the English-language literature published between 1966 and December 1998 on the diagnostic accuracy of out-of-hospital ECG and the clinical effect of out-of-hospital thrombolysis. Both prospective and retrospective studies qualified for the assessment of diagnostic performance. For clinical effect, data from prospective nonrandomized studies were synthesized separately from data from randomized trials. Diagnostic performance was assessed by using estimates of test sensitivity, specificity, and diagnostic odds ratios and was summarized by using summary receiver-operating characteristic curves. Measures of clinical effect included time savings, early ventricular function, early mortality, and long-term survival.\nRESULTS: Diagnostic accuracy was evaluated in 11 studies with a total of 7,508 patients. Data were available for ACI in 5 studies and for AMI in 8 studies. For ACI, the random-effects pooled sensitivity was 76% (95% CI, 54% to 89%), the specificity was 88% (95% CI, 67% to 96%), and the diagnostic odds ratio was 23 (95% CI, 6.3 to 85). The respective figures for AMI were sensitivity of 68% (95% CI, 59% to 76%), specificity of 97% (95% CI, 89% to 92%), and diagnostic odds ratio of 104 (95% CI, 48 to 224). Both in nonrandomized (n=4, total 1,531 patients) and randomized (n=9, total 6,643 patients) studies, out-of-hospital thrombolysis shortened the time from onset of symptoms to thrombolytic treatment by 40 to 60 minutes. Data on short-term ejection fraction were sparse. Hospital mortality was reduced by 16% (95% CI, 2% to 27%) among randomized trials, and a similar estimate of effect was seen in nonrandomized studies. There was no clear effect on long-term mortality, but data were sparse.\nCONCLUSION: Out-of-hospital ECG has excellent diagnostic performance for AMI and very good performance for ACI. Out-of-hospital thrombolysis achieves time savings and improves short-term mortality, but the effect on long-term mortality is unknown.","container-title":"Annals of Emergency Medicine","DOI":"10.1067/mem.2001.114904","ISSN":"0196-0644","issue":"5","journalAbbreviation":"Ann Emerg Med","language":"eng","note":"PMID: 11326182","page":"461-470","source":"PubMed","title":"Accuracy and clinical effect of out-of-hospital electrocardiography in the diagnosis of acute cardiac ischemia: a meta-analysis","title-short":"Accuracy and clinical effect of out-of-hospital electrocardiography in the diagnosis of acute cardiac ischemia","volume":"37","author":[{"family":"Ioannidis","given":"J. P."},{"family":"Salem","given":"D."},{"family":"Chew","given":"P. W."},{"family":"Lau","given":"J."}],"issued":{"date-parts":[["2001",5]]}}}],"schema":""} 7,8. The importance of timely pre-hospital recognition of STEMI is well established ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"irs6QWZh","properties":{"formattedCitation":"\\super 7\\nosupersub{}","plainCitation":"7","noteIndex":0},"citationItems":[{"id":328,"uris":[""],"uri":[""],"itemData":{"id":328,"type":"article-journal","container-title":"Circulation","DOI":"10.1161/CIRCULATIONAHA.108.190402","ISSN":"1524-4539","issue":"10","journalAbbreviation":"Circulation","language":"eng","note":"PMID: 18703464","page":"1066-1079","source":"PubMed","title":"Implementation and integration of prehospital ECGs into systems of care for acute coronary syndrome: a scientific statement from the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee, Council on Cardiovascular Nursing, and Council on Clinical Cardiology","title-short":"Implementation and integration of prehospital ECGs into systems of care for acute coronary syndrome","volume":"118","author":[{"family":"Ting","given":"Henry H."},{"family":"Krumholz","given":"Harlan M."},{"family":"Bradley","given":"Elizabeth H."},{"family":"Cone","given":"David C."},{"family":"Curtis","given":"Jeptha P."},{"family":"Drew","given":"Barbara J."},{"family":"Field","given":"John M."},{"family":"French","given":"William J."},{"family":"Gibler","given":"W. Brian"},{"family":"Goff","given":"David C."},{"family":"Jacobs","given":"Alice K."},{"family":"Nallamothu","given":"Brahmajee K."},{"family":"O'Connor","given":"Robert E."},{"family":"Schuur","given":"Jeremiah D."},{"literal":"American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research, Emergency Cardiovascular Care Committee"},{"literal":"American Heart Association Council on Cardiovascular Nursing"},{"literal":"American Heart Association Council on Clinical Cardiology"}],"issued":{"date-parts":[["2008",9,2]]}}}],"schema":""} 7, yet there are still recognised difficulties. Pre-hospital difficulties include the absence of complete medical records and lack of diagnostic support tools, such as imaging, which increases the risk of ACS misdiagnosis and creates a low positive predictive value for pre-hospital ACS diagnosis ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"jz67LR0h","properties":{"formattedCitation":"\\super 9\\nosupersub{}","plainCitation":"9","noteIndex":0},"citationItems":[{"id":290,"uris":[""],"uri":[""],"itemData":{"id":290,"type":"article-journal","abstract":"Introduction\nPrehospital emergency medicine is a challenging discipline characterized by a high level of acuity, a lack of clinical information and a wide range of clinical conditions. These factors contribute to the fact that prehospital emergency medicine is a high-risk discipline in terms of medical errors. Prehospital use of Computerized Decision Support System (CDSS) may be a way to increase patient safety but very few studies evaluate the effect in prehospital care. The aim of the present study is to evaluate a CDSS.\nMethods\nIn this non-blind block randomized, controlled trial, 60 ambulance nurses participated, randomized into 2 groups. To compensate for an expected learning effect the groups was further divided in two groups, one started with case A and the other group started with case B. The intervention group had access to and treated the two simulated patient cases with the aid of a CDSS. The control group treated the same cases with the aid of a regional guideline in paper format. The performance that was measured was compliance with regional prehospital guidelines and On Scene Time (OST).\nResults\nThere was no significant difference in the two group's characteristics. The intervention group had a higher compliance in the both cases, 80% vs. 60% (p<0.001) but the control group was complete the cases in the half of the time compare to the intervention group (p<0.001).\nConclusion\nThe results indicate that this CDSS increases the ambulance nurses' compliance with regional prehospital guidelines but at the expense of an increase in OST.","container-title":"The American Journal of Emergency Medicine","DOI":"10.1016/j.ajem.2012.06.030","ISSN":"0735-6757","issue":"1","journalAbbreviation":"The American Journal of Emergency Medicine","page":"145-153","source":"ScienceDirect","title":"Decision support system in prehospital care: a randomized controlled simulation study","title-short":"Decision support system in prehospital care","volume":"31","author":[{"family":"Hagiwara","given":"Magnus Andersson"},{"family":"Sj?qvist","given":"Bengt Arne"},{"family":"Lundberg","given":"Lars"},{"family":"Suserud","given":"Bj?rn-Ove"},{"family":"Henricson","given":"Maria"},{"family":"Jonsson","given":"Anders"}],"issued":{"date-parts":[["2013",1,1]]}}}],"schema":""} 9. A low positive predictive value increases inappropriate treatment of ACS including cardiac catheterisation laboratory (‘cath-lab’) activation ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"sFtOVUj8","properties":{"formattedCitation":"\\super 10\\nosupersub{}","plainCitation":"10","noteIndex":0},"citationItems":[{"id":427,"uris":[""],"uri":[""],"itemData":{"id":427,"type":"article-journal","abstract":"Objective\nFor patients with acute myocardial infarction (AMI), symptoms assessed by emergency medical services (EMS) providers have a critical role in prehospital treatment decisions. The purpose of this study was to evaluate the diagnostic accuracy of EMS provider-assessed cardiac symptoms of AMI.\n\nMethods\nPatients transported by EMS to 4 study hospitals from 2008 to 2012 were included. Using EMS and administrative emergency department databases, patients were stratified according to the presence of EMS-assessed cardiac symptoms and emergency department diagnosis of AMI. Cardiac symptoms were defined as chest pain, dyspnea, palpitations, and syncope. Disproportionate stratified sampling was used, and medical records of sampled patients were reviewed to identify an actual diagnosis of AMI. Using inverse probability weighting, verification bias-corrected diagnostic performance was estimated.\n\nResults\nOverall, 92,353 patients were enrolled in the study. Of these, 13,971 (15.1%) complained of cardiac symptoms to EMS providers. A total of 775 patients were sampled for hospital record review. The sensitivity, specificity, positive predictive value, and negative predictive value of EMS provider-assessed cardiac symptoms for the final diagnosis of AMI was 73.3% (95% confidence interval [CI], 70.8 to 75.7), 85.3% (95% CI, 85.3 to 85.4), 3.9% (95% CI, 3.6 to 4.2), and 99.7% (95% CI, 99.7 to 99.8), respectively.\n\nConclusion\nWe found that EMS provider-assessed cardiac symptoms had moderate sensitivity and high specificity for diagnosis of AMI. EMS policymakers can use these data to evaluate the pertinence of specific prehospital treatment of AMI.","container-title":"Clinical and Experimental Emergency Medicine","DOI":"10.15441/ceem.17.257","ISSN":"2383-4625","issue":"4","journalAbbreviation":"Clin Exp Emerg Med","note":"PMID: 30571905\nPMCID: PMC6301859","page":"264-271","source":"PubMed Central","title":"Sensitivity, specificity, and predictive value of cardiac symptoms assessed by emergency medical services providers in the diagnosis of acute myocardial infarction: a multi-center observational study","title-short":"Sensitivity, specificity, and predictive value of cardiac symptoms assessed by emergency medical services providers in the diagnosis of acute myocardial infarction","volume":"5","author":[{"family":"Park","given":"Jeong Ho"},{"family":"Moon","given":"Sung Woo"},{"family":"Kim","given":"Tae Yun"},{"family":"Ro","given":"Young Sun"},{"family":"Cha","given":"Won Chul"},{"family":"Kim","given":"Yu Jin"},{"family":"Shin","given":"Sang Do"}],"issued":{"date-parts":[["2018",12,31]]}}}],"schema":""} 10. Over activation of the cath-lab is a potentially avoidable strain on a valuable clinical resource. False mobilisation increases workload of the cath-lab team and often requires unnecessary redirection of emergency medical services to deliver patients to cath-lab centres outside their normal operating zones. Conversely, under-diagnosis of STEMI has obvious negative consequences. Delayed presentation of STEMI has significantly decreased long-term survival rates (73% survival with late presenters versus 93% survival with early presenters) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"iZ2xiKe4","properties":{"formattedCitation":"\\super 11\\nosupersub{}","plainCitation":"11","noteIndex":0},"citationItems":[{"id":646,"uris":[""],"uri":[""],"itemData":{"id":646,"type":"article-journal","abstract":"?\n A proportion of patients with acute myocardial infarction present late after symptom onset.\n \n \n ?\n Women, diabetics and patients who do not experience typical chest pain are more likely to present late.\n \n \n ?\n Patients with myocardial infarction who present late have increased mortality at one year.","container-title":"International Journal of Cardiology. Heart & Vasculature","DOI":"10.1016/j.ijcha.2019.02.002","ISSN":"2352-9067","journalAbbreviation":"Int J Cardiol Heart Vasc","note":"PMID: 30828600\nPMCID: PMC6383163","page":"156-159","source":"PubMed Central","title":"Very late presentation in ST elevation myocardial infarction: Predictors and long-term mortality","title-short":"Very late presentation in ST elevation myocardial infarction","volume":"22","author":[{"family":"McNair","given":"Patrick W."},{"family":"Bilchick","given":"Kenneth C."},{"family":"Keeley","given":"Ellen C."}],"issued":{"date-parts":[["2019",2,20]]}}}],"schema":""} 11 and even late treatment of STEMI via reperfusion of the culprit occluded artery has no benefit in mortality compared to conservative medical therapy ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"vHvEOzfR","properties":{"formattedCitation":"\\super 12\\nosupersub{}","plainCitation":"12","noteIndex":0},"citationItems":[{"id":649,"uris":[""],"uri":[""],"itemData":{"id":649,"type":"article-journal","abstract":"BACKGROUND: It is unclear whether stable, high-risk patients with persistent total occlusion of the infarct-related coronary artery identified after the currently accepted period for myocardial salvage has passed should undergo percutaneous coronary intervention (PCI) in addition to receiving optimal medical therapy to reduce the risk of subsequent events.\nMETHODS: We conducted a randomized study involving 2166 stable patients who had total occlusion of the infarct-related artery 3 to 28 days after myocardial infarction and who met a high-risk criterion (an ejection fraction of <50% or proximal occlusion). Of these patients, 1082 were assigned to routine PCI and stenting with optimal medical therapy, and 1084 were assigned to optimal medical therapy alone. The primary end point was a composite of death, myocardial reinfarction, or New York Heart Association (NYHA) class IV heart failure.\nRESULTS: The 4-year cumulative primary event rate was 17.2% in the PCI group and 15.6% in the medical therapy group (hazard ratio for death, reinfarction, or heart failure in the PCI group as compared with the medical therapy group, 1.16; 95% confidence interval [CI], 0.92 to 1.45; P=0.20). Rates of myocardial reinfarction (fatal and nonfatal) were 7.0% and 5.3% in the two groups, respectively (hazard ratio, 1.36; 95% CI, 0.92 to 2.00; P=0.13). Rates of nonfatal reinfarction were 6.9% and 5.0%, respectively (hazard ratio, 1.44; 95% CI, 0.96 to 2.16; P=0.08); only six reinfarctions (0.6%) were related to assigned PCI procedures. Rates of NYHA class IV heart failure (4.4% vs. 4.5%) and death (9.1% vs. 9.4%) were similar. There was no interaction between treatment effect and any subgroup variable (age, sex, race or ethnic group, infarct-related artery, ejection fraction, diabetes, Killip class, and the time from myocardial infarction to randomization).\nCONCLUSIONS: PCI did not reduce the occurrence of death, reinfarction, or heart failure, and there was a trend toward excess reinfarction during 4 years of follow-up in stable patients with occlusion of the infarct-related artery 3 to 28 days after myocardial infarction. ( number, NCT00004562 [].).","container-title":"The New England Journal of Medicine","DOI":"10.1056/NEJMoa066139","ISSN":"1533-4406","issue":"23","journalAbbreviation":"N. Engl. J. Med.","language":"eng","note":"PMID: 17105759\nPMCID: PMC1995554","page":"2395-2407","source":"PubMed","title":"Coronary intervention for persistent occlusion after myocardial infarction","volume":"355","author":[{"family":"Hochman","given":"Judith S."},{"family":"Lamas","given":"Gervasio A."},{"family":"Buller","given":"Christopher E."},{"family":"Dzavik","given":"Vladimir"},{"family":"Reynolds","given":"Harmony R."},{"family":"Abramsky","given":"Staci J."},{"family":"Forman","given":"Sandra"},{"family":"Ruzyllo","given":"Witold"},{"family":"Maggioni","given":"Aldo P."},{"family":"White","given":"Harvey"},{"family":"Sadowski","given":"Zygmunt"},{"family":"Carvalho","given":"Antonio C."},{"family":"Rankin","given":"Jamie M."},{"family":"Renkin","given":"Jean P."},{"family":"Steg","given":"P. Gabriel"},{"family":"Mascette","given":"Alice M."},{"family":"Sopko","given":"George"},{"family":"Pfisterer","given":"Matthias E."},{"family":"Leor","given":"Jonathan"},{"family":"Fridrich","given":"Viliam"},{"family":"Mark","given":"Daniel B."},{"family":"Knatterud","given":"Genell L."},{"literal":"Occluded Artery Trial Investigators"}],"issued":{"date-parts":[["2006",12,7]]}}}],"schema":""} 12. In addition, subtypes of ACS such as non-ST elevation myocardial infarction (NSTEMI) and unstable angina can be just as critical as a STEMI as ST elevation on the ECG is not exclusive for acute coronary artery occlusion ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"EQ8c7Tgt","properties":{"formattedCitation":"\\super 13\\nosupersub{}","plainCitation":"13","noteIndex":0},"citationItems":[{"id":604,"uris":[""],"uri":[""],"itemData":{"id":604,"type":"article-journal","abstract":"BACKGROUND: In acute coronary syndrome (ACS), ST-segment elevation (STE), often associated with a completely occluded culprit artery, is an important ECG criterion for primary percutaneous coronary intervention (PCI). However, several studies showed that in ACS a completely occluded culprit artery can also occur with a non-ST-elevation (NSTE) ECG. In order to elucidate reasons for this discrepancy we examined ST injury vector orientation and magnitude in ACS patients with and without STE, all admitted for primary PCI and having a completely occluded culprit artery.\nMETHODS: We studied the ECGs of 300 ACS patients (214/86 STE/NSTE; 228/72 single/multivessel disease) who had a completely occluded culprit artery during angiography prior to primary PCI. The J+60 injury vector orientation and magnitude were computed from Frank XYZ leads derived from the 10-s standard 12-lead ECG.\nRESULTS: Demographic and anthropomorphic characteristics of the STE and NSTE patients did not differ. STE patients had a higher rate of right coronary artery occlusions, and a lower rate of left circumflex occlusions than NSTE patients (43 vs. 31%, and 13 vs. 22%, respectively; P<0.05). Injury vector elevation and magnitude were larger in STE than in NSTE patients (32° ± 37° vs. 6° ± 39°, and 304 ± 145 μV vs. 134 ± 72 μV, respectively; P<0.0001).\nCONCLUSION: STE criteria favor certain injury vector directions and larger injury vector magnitudes. Obviously, several ACS patients with complete culprit artery occlusions requiring primary PCI do not fulfill these criteria. Our study suggests that STE-NSTE-based ACS stratification needs further enhancement.","container-title":"Journal of Electrocardiology","DOI":"10.1016/j.jelectrocard.2013.11.009","ISSN":"1532-8430","issue":"2","journalAbbreviation":"J Electrocardiol","language":"eng","note":"PMID: 24388489","page":"183-190","source":"PubMed","title":"Acute coronary syndrome with a totally occluded culprit artery: relation of the ST injury vector with ST-elevation and non-ST elevation ECGs","title-short":"Acute coronary syndrome with a totally occluded culprit artery","volume":"47","author":[{"family":"Man","given":"Sumche"},{"family":"Rahmattulla","given":"Chinar"},{"family":"Maan","given":"Arie C."},{"family":"Putten","given":"Niek H. J. J.","non-dropping-particle":"van der"},{"family":"Dijk","given":"W. Arnold"},{"family":"Zwet","given":"Erik W.","non-dropping-particle":"van"},{"family":"Wall","given":"Ernst E.","non-dropping-particle":"van der"},{"family":"Schalij","given":"Martin J."},{"family":"Gorgels","given":"Anton P."},{"family":"Swenne","given":"Cees A."}],"issued":{"date-parts":[["2014",4]]}}}],"schema":""} 13 i.e. a proportion of NSTEMI are actually caused by an occluded coronary artery. Clinical decision support systems (CDSS) are platforms that combine multiple clinical data inputs (termed “components” in this review) to produce a single output, which can be a diagnosis, clinical advice or risk stratification, that can help clinicians with difficult decision making ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"IRGp2v6s","properties":{"formattedCitation":"\\super 9\\nosupersub{}","plainCitation":"9","noteIndex":0},"citationItems":[{"id":290,"uris":[""],"uri":[""],"itemData":{"id":290,"type":"article-journal","abstract":"Introduction\nPrehospital emergency medicine is a challenging discipline characterized by a high level of acuity, a lack of clinical information and a wide range of clinical conditions. These factors contribute to the fact that prehospital emergency medicine is a high-risk discipline in terms of medical errors. Prehospital use of Computerized Decision Support System (CDSS) may be a way to increase patient safety but very few studies evaluate the effect in prehospital care. The aim of the present study is to evaluate a CDSS.\nMethods\nIn this non-blind block randomized, controlled trial, 60 ambulance nurses participated, randomized into 2 groups. To compensate for an expected learning effect the groups was further divided in two groups, one started with case A and the other group started with case B. The intervention group had access to and treated the two simulated patient cases with the aid of a CDSS. The control group treated the same cases with the aid of a regional guideline in paper format. The performance that was measured was compliance with regional prehospital guidelines and On Scene Time (OST).\nResults\nThere was no significant difference in the two group's characteristics. The intervention group had a higher compliance in the both cases, 80% vs. 60% (p<0.001) but the control group was complete the cases in the half of the time compare to the intervention group (p<0.001).\nConclusion\nThe results indicate that this CDSS increases the ambulance nurses' compliance with regional prehospital guidelines but at the expense of an increase in OST.","container-title":"The American Journal of Emergency Medicine","DOI":"10.1016/j.ajem.2012.06.030","ISSN":"0735-6757","issue":"1","journalAbbreviation":"The American Journal of Emergency Medicine","page":"145-153","source":"ScienceDirect","title":"Decision support system in prehospital care: a randomized controlled simulation study","title-short":"Decision support system in prehospital care","volume":"31","author":[{"family":"Hagiwara","given":"Magnus Andersson"},{"family":"Sj?qvist","given":"Bengt Arne"},{"family":"Lundberg","given":"Lars"},{"family":"Suserud","given":"Bj?rn-Ove"},{"family":"Henricson","given":"Maria"},{"family":"Jonsson","given":"Anders"}],"issued":{"date-parts":[["2013",1,1]]}}}],"schema":""} 9. For instance, CDSS have already been developed for use in the emergency department for ACS ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ZmiJL2YO","properties":{"formattedCitation":"\\super 14,15\\nosupersub{}","plainCitation":"14,15","noteIndex":0},"citationItems":[{"id":454,"uris":[""],"uri":[""],"itemData":{"id":454,"type":"article-journal","abstract":"OBJECTIVES: The rapid turnaround time of point-of-care (POC) cardiac troponin (cTn) assays is highly attractive for crowded emergency departments (EDs). We evaluated the diagnostic accuracy of the Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid with a POC cTn assay.\nMETHODS: In a prospective diagnostic accuracy study at eight EDs, we included patients with suspected acute coronary syndromes (ACS). Blood drawn on arrival and 3?hours later was analysed for POC cTnI (i-Stat, Abbott Point of Care). The primary outcome was a diagnosis of ACS, which included both an adjudicated diagnosis of acute myocardial infarction (AMI) based on serial laboratory cTn testing and major adverse cardiac events (death, AMI or coronary revascularisation) within 30 days.\nRESULTS: Of 716 patients included, 105 (14.7%) had ACS. Using serial POC cTnI concentrations over 3?hours could have 'ruled out' ACS in 198 (31.2%) patients with a sensitivity of 99.0% (95% CI 94.4% to 100.0%) and negative predictive value 99.5% (95% CI 96.5% to 99.9%). No AMIs were missed. T-MACS 'ruled in' ACS for 65 (10.4%) patients with a positive predictive value of 91.2% (95% CI 82.1% to 95.9%) and specificity 98.9% (97.6% to 99.6%).\nCONCLUSION: With a POC cTnI assay, T-MACS could 'rule out' ACS for approximately one-third of patients within 3?hours while 'ruling in' ACS for another 10%. The rapid turnaround time and portability of the POC assay make this an attractive pathway for use in crowded EDs or urgent care centres. Future work should also evaluate use in the prehospital environment.","container-title":"Heart (British Cardiac Society)","DOI":"10.1136/heartjnl-2018-313825","ISSN":"1468-201X","journalAbbreviation":"Heart","language":"eng","note":"PMID: 30636217","source":"PubMed","title":"Diagnostic accuracy of the T-MACS decision aid with a contemporary point-of-care troponin assay","author":[{"family":"Body","given":"Richard"},{"family":"Almashali","given":"Malak"},{"family":"Morris","given":"Niall"},{"family":"Moss","given":"Phil"},{"family":"Jarman","given":"Heather"},{"family":"Appelboam","given":"Andrew"},{"family":"Parris","given":"Richard"},{"family":"Chan","given":"Louisa"},{"family":"Walker","given":"Alison"},{"family":"Harrison","given":"Mark"},{"family":"Wootten","given":"Andrea"},{"family":"McDowell","given":"Garry"}],"issued":{"date-parts":[["2019",1,12]]}}},{"id":653,"uris":[""],"uri":[""],"itemData":{"id":653,"type":"article-journal","abstract":"BACKGROUND: Several models for prediction of acute coronary syndrome (ACS) among chest pain patients in the emergency department (ED) have been presented, but many models predict only the likelihood of acute myocardial infarction, or include a large number of variables, which make them less than optimal for implementation at a busy ED. We report here a simple statistical model for ACS prediction that could be used in routine care at a busy ED.\nMETHODS: Multivariable analysis and logistic regression were used on data from 634 ED visits for chest pain. Only data immediately available at patient presentation were used. To make ACS prediction stable and the model useful for personnel inexperienced in electrocardiogram (ECG) reading, simple ECG data suitable for computerized reading were included.\nRESULTS: Besides ECG, eight variables were found to be important for ACS prediction, and included in the model: age, chest discomfort at presentation, symptom duration and previous hypertension, angina pectoris, AMI, congestive heart failure or PCI/CABG. At an ACS prevalence of 21% and a set sensitivity of 95%, the negative predictive value of the model was 96%.\nCONCLUSION: The present prediction model, combined with the clinical judgment of ED personnel, could be useful for the early discharge of chest pain patients in populations with a low prevalence of ACS.","container-title":"BMC medical informatics and decision making","DOI":"10.1186/1472-6947-6-28","ISSN":"1472-6947","journalAbbreviation":"BMC Med Inform Decis Mak","language":"eng","note":"PMID: 16824205\nPMCID: PMC1559601","page":"28","source":"PubMed","title":"A simple statistical model for prediction of acute coronary syndrome in chest pain patients in the emergency department","volume":"6","author":[{"family":"Bj?rk","given":"Jonas"},{"family":"Forberg","given":"Jakob L."},{"family":"Ohlsson","given":"Mattias"},{"family":"Edenbrandt","given":"Lars"},{"family":"Ohlin","given":"Hans"},{"family":"Ekelund","given":"Ulf"}],"issued":{"date-parts":[["2006",7,6]]}}}],"schema":""} 14,15, where these tend to focus on a high negative predictive value to prioritise safe discharge. In the community, there is increased difficulty for out-of-hospital practitioners, like general practitioners (especially those in remote and rural communities) and ambulance crews, to make triage decisions in patients with ACS without the clinical diagnostic tools that are available in the hospital. These difficulties are compounded with suspected ACS that presents without obvious ST elevation as a non-diagnostic ECG creates further ambiguity. This challenge has been the target of CDSS-related research to assist pre-hospital clinicians to manage patients who have suspected ACS ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Hm6Zpz44","properties":{"formattedCitation":"\\super 16\\nosupersub{}","plainCitation":"16","noteIndex":0},"citationItems":[{"id":435,"uris":[""],"uri":[""],"itemData":{"id":435,"type":"article-journal","abstract":"BACKGROUND:: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE).\nMETHODS:: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ? 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death.\nRESULTS:: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%).\nCONCLUSIONS:: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872618813846","ISSN":"2048-8734","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 30468395","page":"2048872618813846","source":"PubMed","title":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study","title-short":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome","author":[{"family":"Dongen","given":"Dominique N.","non-dropping-particle":"van"},{"family":"Tolsma","given":"Rudolf T."},{"family":"Fokkert","given":"Marion J."},{"family":"Badings","given":"Erik A."},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Slingerland","given":"Robbert J."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"},{"family":"Ottervanger","given":"Jan Paul"}],"issued":{"date-parts":[["2018",11,23]]}}}],"schema":""} 16. With great interrogation of technology into healthcare, there is a large potential for computer-aided diagnosis of ACS in the pre-hospital setting. Computer-aided decision support has already been shown to be beneficial determining allocation for level of life support in the emergency department ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"mT3WIpUn","properties":{"formattedCitation":"\\super 17\\nosupersub{}","plainCitation":"17","noteIndex":0},"citationItems":[{"id":698,"uris":[""],"uri":[""],"itemData":{"id":698,"type":"article-journal","abstract":"OBJECTIVES: To evaluate whether a computer-based decision support system could be useful for the emergency medical system when identifying patients with acute myocardial infarction (AMI) or life-threatening conditions and thereby improve the allocation of life support level.\nMETHODS: Patients in the Municipality of G?teborg who dialled the dispatch centre due to chest pain during a period of 3 months. To analyse the relationship between patient characteristics (according to a case record form used during an interview) and the response variables (AMI or life-threatening condition), multivariate logistic regression was used. For each patient, the probability of AMI/life-threatening condition was estimated by the model. We used these probabilities retrospectively to allocate advanced life support or basic life support. This model allocation was then compared with the true allocation made by the dispatchers.\nRESULTS: The sensitivity, that is, the percentage of AMI patients allocated to advanced life support, was 85.7% in relation to the true allocation made by the dispatchers. The corresponding sensitivity regarding allocation made by the model was 92.4% (P=0.17). The specificity was also slightly higher for the model allocation than the dispatcher allocation. Among the 15 patients with AMI who were allocated to basic life support by the dispatchers, nine died (eight during and one after hospitalization). Among the eight patients with AMI allocated to basic life support by the model, only one patient died (in hospital) (P=0.02).\nCONCLUSION: A computer-based decision support system including a prevalence function could be a valuable tool for allocating the level of life support. The case record form, however, used for the interview can be refined and a model based on a larger sample and confirmed in a prospective study is recommended.","container-title":"European Journal of Emergency Medicine: Official Journal of the European Society for Emergency Medicine","ISSN":"0969-9546","issue":"5","journalAbbreviation":"Eur J Emerg Med","language":"eng","note":"PMID: 16969235","page":"290-294","source":"PubMed","title":"Could a computer-based system including a prevalence function support emergency medical systems and improve the allocation of life support level?","volume":"13","author":[{"family":"Gellerstedt","given":"Martin"},{"family":"B?ng","given":"Angela"},{"family":"Herlitz","given":"Johan"}],"issued":{"date-parts":[["2006",10]]}}}],"schema":""} 17. In addition, computer-aided ECG interpretation algorithms have been developed to improve pre-hospital and emergency department ACS identification to reduce the delay or misdiagnosis of ACS associated with prolonged door-to-balloon time ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"w0mWMGRD","properties":{"formattedCitation":"\\super 18\\nosupersub{}","plainCitation":"18","noteIndex":0},"citationItems":[{"id":700,"uris":[""],"uri":[""],"itemData":{"id":700,"type":"article-journal","abstract":"Computerized interpretation of the electrocardiogram (CIE) was introduced to improve the correct interpretation of the electrocardiogram (ECG), facilitating health care decision making and reducing costs. Worldwide, millions of ECGs are recorded annually, with the majority automatically analyzed, followed by an immediate interpretation. Limitations in the diagnostic accuracy of CIE were soon recognized and still persist, despite ongoing improvement in ECG algorithms. Unfortunately, inexperienced physicians ordering the ECG may fail to recognize interpretation mistakes and accept the automated diagnosis without criticism. Clinical mismanagement may result, with the risk of exposing patients to useless?investigations or potentially dangerous treatment. Consequently, CIE over-reading and confirmation by an experienced ECG reader are essential and are repeatedly recommended in published reports. Implementation of new ECG knowledge is also important. The current status of automated ECG interpretation is reviewed, with suggestions for improvement.","container-title":"Journal of the American College of Cardiology","DOI":"10.1016/j.jacc.2017.07.723","ISSN":"1558-3597","issue":"9","journalAbbreviation":"J. Am. Coll. Cardiol.","language":"eng","note":"PMID: 28838369","page":"1183-1192","source":"PubMed","title":"Computer-Interpreted Electrocardiograms: Benefits and Limitations","title-short":"Computer-Interpreted Electrocardiograms","volume":"70","author":[{"family":"Schl?pfer","given":"Jürg"},{"family":"Wellens","given":"Hein J."}],"issued":{"date-parts":[["2017",8,29]]}}}],"schema":""} 18. However, computer-aided ECG interpretation is still limited by ECG artefact and other non-ischaemic causes of ST elevation such as early-repolarisation and thus interpretation of the ECG should be done in combination of other components such as symptoms and medical history ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"W7AOGzUc","properties":{"formattedCitation":"\\super 19,20\\nosupersub{}","plainCitation":"19,20","noteIndex":0},"citationItems":[{"id":703,"uris":[""],"uri":[""],"itemData":{"id":703,"type":"article-journal","abstract":"OBJECTIVES: To determine the causes of software misinterpretation of ST elevation myocardial infarction (STEMI) compared to clinically identified STEMI to identify opportunities to improve prehospital STEMI identification.\nMETHODS: We compared ECGs acquired from July 2011 through June 2012 using the LIFEPAK 15 on adult patients transported by the Los Angeles Fire Department. Cases included patients ≥18?years who received a prehospital ECG. Software interpretation of the ECG (STEMI or not) was compared with data in the regional EMS registry to classify the interpretation as true positive (TP), true negative (TN), false positive (FP), or false negative (FN). For cases where classification was not possible using registry data, 3 blinded cardiologists interpreted the ECG. Each discordance was subsequently reviewed to determine the likely cause of misclassification. The cardiologists independently reviewed a sample of these discordant ECGs and the causes of misclassification were updated in an iterative fashion.\nRESULTS: Of 44,611 cases, 50% were male (median age 65; inter-quartile range 52-80). Cases were classified as 482 (1.1%) TP, 711 (1.6%) FP, 43371 (97.2%) TN, and 47 (0.11%) FN. Of the 711 classified as FP, 126 (18%) were considered appropriate for, though did not undergo, emergent coronary angiography, because the ECG showed definite (52 cases) or borderline (65 cases) ischemic ST elevation, a STEMI equivalent (5 cases) or ST-elevation due to vasospasm (4 cases). The sensitivity was 92.8% [95% CI 90.6, 94.7%] and the specificity 98.7% [95% CI 98.6, 98.8%]. The leading causes of FP were ECG artifact (20%), early repolarization (16%), probable pericarditis/myocarditis (13%), indeterminate (12%), left ventricular hypertrophy (8%), and right bundle branch block (5%). There were 18 additional reasons for FP interpretation (<4% each). The leading causes of FN were borderline ST-segment elevations less than the algorithm threshold (40%) and tall T waves reducing the ST/T ratio below threshold (15%). There were 11 additional reasons for FN interpretation occurring ≤3?times each.\nCONCLUSION: The leading causes of FP automated interpretation of STEMI were ECG artifact and non-ischemic causes of ST-segment elevation. FN were rare and were related to ST-segment elevation or ST/T ratio that did not meet the software algorithm threshold.","container-title":"Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors","DOI":"10.1080/10903127.2016.1247200","ISSN":"1545-0066","issue":"3","journalAbbreviation":"Prehosp Emerg Care","language":"eng","note":"PMID: 27858506","page":"283-290","source":"PubMed","title":"Causes of Prehospital Misinterpretations of ST Elevation Myocardial Infarction","volume":"21","author":[{"family":"Bosson","given":"Nichole"},{"family":"Sanko","given":"Stephen"},{"family":"Stickney","given":"Ronald E."},{"family":"Niemann","given":"James"},{"family":"French","given":"William J."},{"family":"Jollis","given":"James G."},{"family":"Kontos","given":"Michael C."},{"family":"Taylor","given":"Tyson G."},{"family":"Macfarlane","given":"Peter W."},{"family":"Tadeo","given":"Richard"},{"family":"Koenig","given":"William"},{"family":"Eckstein","given":"Marc"}],"issued":{"date-parts":[["2017",6]]}}},{"id":445,"uris":[""],"uri":[""],"itemData":{"id":445,"type":"article-journal","abstract":"BACKGROUND: Identifying ST-segment elevation myocardial infarctions (STEMIs) in the field can decrease door-to-balloon times. Paramedics may use a computer algorithm to help them interpret prehospital electrocariograms (ECGs). It is unknown how accurately the computer can identify STEMIs.\nOBJECTIVES: To Determine the sensitivity and specificity of prehospital ECGs in identifying patients with STEMI.\nMETHODS: Retrospective cross-sectional study of 200 prehospital ECGs acquired using Lifepak 12 monitors and transmitted by one of more than 20 emergency medical services (EMS) agencies to the emergency department (ED) of a Summa Akron City Hospital, a level 1 trauma center between January 1, 2007, and February 18, 2010. The ED sees more than 73,000 adult patients and treats 120 STEMIs annually. The laboratory performs 3,400 catheterizations annually. The first 100 patients with a diagnosis of STEMI and cardiac catheterization laboratory activation from the ED were analyzed. For comparison, a control group of 100 other ECGs from patients without a STEMI were randomly selected from our Medtronic database using a random-number generator. For patients with STEMI, an accurate computer interpretation was \"acute MI suspected.\" Other interpretations were counted as misses. Specificity and sensitivity were calculated with confidence intervals (CIs). The sample size was determined a priori for a 95% CI of ±10%.\nRESULTS: Zero control patients were incorrectly labeled \"acute MI suspected.\" The specificity was 100% (100/100; 95% CI 0.96-1.0), whereas the sensitivity was 58% (58/100; 95% CI 0.48-0.67). This would have resulted in 42 missed cardiac catheterization laboratory activations, but zero inappropriate activations. The most common incorrect interpretation of STEMI ECGs by the computer was \"data quality prohibits interpretation,\" followed by \"abnormal ECG unconfirmed.\"\nCONCLUSIONS: Prehospital computer interpretation is not sensitive for STEMI identification and should not be used as a single method for prehospital activation of the cardiac catheterizing laboratory. Because of its high specificity, it may serve as an adjunct to interpretation.","container-title":"Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors","DOI":"10.3109/10903127.2012.722176","ISSN":"1545-0066","issue":"2","journalAbbreviation":"Prehosp Emerg Care","language":"eng","note":"PMID: 23066910","page":"211-216","source":"PubMed","title":"Prehospital electrocardiographic computer identification of ST-segment elevation myocardial infarction","volume":"17","author":[{"family":"Bhalla","given":"Mary Colleen"},{"family":"Mencl","given":"Francis"},{"family":"Gist","given":"Mikki Amber"},{"family":"Wilber","given":"Scott"},{"family":"Zalewski","given":"Jon"}],"issued":{"date-parts":[["2013",6]]}}}],"schema":""} 19,20.In the pre-hospital environment, there are concerns that CDSS can cause delays compared to standard care ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Ix6kkZli","properties":{"formattedCitation":"\\super 9\\nosupersub{}","plainCitation":"9","noteIndex":0},"citationItems":[{"id":290,"uris":[""],"uri":[""],"itemData":{"id":290,"type":"article-journal","abstract":"Introduction\nPrehospital emergency medicine is a challenging discipline characterized by a high level of acuity, a lack of clinical information and a wide range of clinical conditions. These factors contribute to the fact that prehospital emergency medicine is a high-risk discipline in terms of medical errors. Prehospital use of Computerized Decision Support System (CDSS) may be a way to increase patient safety but very few studies evaluate the effect in prehospital care. The aim of the present study is to evaluate a CDSS.\nMethods\nIn this non-blind block randomized, controlled trial, 60 ambulance nurses participated, randomized into 2 groups. To compensate for an expected learning effect the groups was further divided in two groups, one started with case A and the other group started with case B. The intervention group had access to and treated the two simulated patient cases with the aid of a CDSS. The control group treated the same cases with the aid of a regional guideline in paper format. The performance that was measured was compliance with regional prehospital guidelines and On Scene Time (OST).\nResults\nThere was no significant difference in the two group's characteristics. The intervention group had a higher compliance in the both cases, 80% vs. 60% (p<0.001) but the control group was complete the cases in the half of the time compare to the intervention group (p<0.001).\nConclusion\nThe results indicate that this CDSS increases the ambulance nurses' compliance with regional prehospital guidelines but at the expense of an increase in OST.","container-title":"The American Journal of Emergency Medicine","DOI":"10.1016/j.ajem.2012.06.030","ISSN":"0735-6757","issue":"1","journalAbbreviation":"The American Journal of Emergency Medicine","page":"145-153","source":"ScienceDirect","title":"Decision support system in prehospital care: a randomized controlled simulation study","title-short":"Decision support system in prehospital care","volume":"31","author":[{"family":"Hagiwara","given":"Magnus Andersson"},{"family":"Sj?qvist","given":"Bengt Arne"},{"family":"Lundberg","given":"Lars"},{"family":"Suserud","given":"Bj?rn-Ove"},{"family":"Henricson","given":"Maria"},{"family":"Jonsson","given":"Anders"}],"issued":{"date-parts":[["2013",1,1]]}}}],"schema":""} 9 and that these systems might reduce the autonomy of clinicians ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"z9cclTvY","properties":{"formattedCitation":"\\super 21\\nosupersub{}","plainCitation":"21","noteIndex":0},"citationItems":[{"id":468,"uris":[""],"uri":[""],"itemData":{"id":468,"type":"article-journal","abstract":"Clinical prediction rules, sometimes called clinical decision rules, have proliferated in recent years. However, very few have undergone formal impact analysis, the standard of evidence to assess their impact on patient care. Without impact analysis, clinicians cannot know whether using a prediction rule will be beneficial or harmful. This paper reviews standards of evidence for developing and evaluating prediction rules; important differences between prediction rules and decision rules; how to assess the potential clinical impact of a prediction rule before translating it into a decision rule; methodologic issues critical to successful impact analysis, including defining outcome measures and estimating sample size; the importance of close collaboration between clinical investigators and practicing clinicians before, during, and after impact analysis; and the need to measure both efficacy and effectiveness when analyzing a decision rule's clinical impact. These considerations should inform future development, evaluation, and use of all clinical prediction or decision rules.","container-title":"Annals of Internal Medicine","ISSN":"1539-3704","issue":"3","journalAbbreviation":"Ann. Intern. Med.","language":"eng","note":"PMID: 16461965","page":"201-209","source":"PubMed","title":"Translating clinical research into clinical practice: impact of using prediction rules to make decisions","title-short":"Translating clinical research into clinical practice","volume":"144","author":[{"family":"Reilly","given":"Brendan M."},{"family":"Evans","given":"Arthur T."}],"issued":{"date-parts":[["2006",2,7]]}}}],"schema":""} 21. However, previous studies have shown the benefit of pre-hospital CDSS for patients with stroke ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"APs4PrGL","properties":{"formattedCitation":"\\super 22\\nosupersub{}","plainCitation":"22","noteIndex":0},"citationItems":[{"id":632,"uris":[""],"uri":[""],"itemData":{"id":632,"type":"article-journal","abstract":"OBJECTIVE: The aim of the Faster Access to Stroke Therapy (FAST) study was to determine the effect of educational intervention and the use of a prehospital stroke tool on the paramedic diagnosis of stroke.\nMETHODS: Paramedics in emergency medical service units servicing a university teaching hospital were divided into two groups: FAST study paramedics (n = 18) and non-FAST study paramedics (n = 43). The FAST study paramedics received stroke education and instruction in the use of a prehospital stroke assessment tool [Melbourne Ambulance Stroke Screen (MASS)] to assist in stroke diagnosis. Based on final hospital diagnosis, the sensitivities of paramedic stroke diagnosis in the two groups were compared for a 12-month period before and after the intervention.\nRESULTS: The sensitivity for the FAST study paramedics in identifying stroke improved from 78% (95% confidence interval [CI]: 63% to 88%) to 94% (95% CI: 86% to 98%) (p = 0.006) after receiving the stroke education session and with use of the MASS tool. There was no change in stroke diagnosis for the non-study paramedics 78% (95% CI: 71% to 84%) to 80% (95% CI: 72% to 87%) (p = 0.695). Pre-notification of impending arrival to the emergency department was associated with higher-priority triage in the emergency department, and subsequent shorter times for door to medical review (15 min vs. 31 min, p < 0.001) and door to computed tomography (CT) scanning (94 min vs. 144 min, p < 0.001).\nCONCLUSIONS: Targeted stroke education and the use of a simple clinical tool can significantly improve the diagnostic sensitivity of stroke by paramedics in the prehospital setting. Accurate diagnosis combined with pre-notification of the pending arrival of stroke patients will allow for the focused and timely application of resources for the management of acute stroke.","container-title":"Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors","DOI":"10.1080/10903120590962382","ISSN":"1090-3127","issue":"3","journalAbbreviation":"Prehosp Emerg Care","language":"eng","note":"PMID: 16147479","page":"297-302","source":"PubMed","title":"An interventional study to improve paramedic diagnosis of stroke","volume":"9","author":[{"family":"Bray","given":"Janet E."},{"family":"Martin","given":"Jenepher"},{"family":"Cooper","given":"Greg"},{"family":"Barger","given":"Bill"},{"family":"Bernard","given":"Stephen"},{"family":"Bladin","given":"Christopher"}],"issued":{"date-parts":[["2005",9]]}}}],"schema":""} 22 and spinal injury ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"0Q9vMCZk","properties":{"formattedCitation":"\\super 23\\nosupersub{}","plainCitation":"23","noteIndex":0},"citationItems":[{"id":634,"uris":[""],"uri":[""],"itemData":{"id":634,"type":"article-journal","abstract":"OBJECTIVE: To describe the utilization and findings with a statewide, prehospital spine-assessment protocol for emergency medical services (EMS) providers in a rural state.\nMETHODS: The study was a prospective sample of EMS patients evaluated by prehospital providers for trauma-related injury during a one-year investigation period. Prehospital providers prospectively completed supplementary spine data-collection forms that reported patient demographics and EMS provider findings with the spine-assessment protocol. Data were analyzed using descriptive statistics.\nRESULTS: There were 207,545 EMS encounters during the study period, including 31,885 transports for acute trauma-related illness. Prehospital providers provided spine-assessment forms for 2,220 patient encounters. Providers reported a decision to immobilize 1,301 (59%) patients. For these immobilized patients, spine protocol findings included 416 (32%) patients deemed as unreliable, 358 (28%) with distracting injury, 80 (6%) with an abnormal neurologic examination, and 709 (54%) with spine pain or tenderness. Linkage of EMS and hospital data revealed seven acute spine fracture patients among the 2,220 reported encounters, all of whom were immobilized by EMS providers.\nCONCLUSIONS: Use of this prehospital spine-assessment protocol resulted in an EMS provider decision not to immobilize approximately 40% of EMS trauma patients. Few spine fracture patients were encountered during the investigational period, though all were immobilized.","container-title":"Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors","DOI":"10.1080/10903120590962003","ISSN":"1090-3127","issue":"3","journalAbbreviation":"Prehosp Emerg Care","language":"eng","note":"PMID: 16147480","page":"303-309","source":"PubMed","title":"EMS provider findings and interventions with a statewide EMS spine-assessment protocol","volume":"9","author":[{"family":"Burton","given":"John H."},{"family":"Harmon","given":"Nathan R."},{"family":"Dunn","given":"Matthew G."},{"family":"Bradshaw","given":"Jay R."}],"issued":{"date-parts":[["2005",9]]}}}],"schema":""} 23. One review looked at pre-hospital CDSS for ACS but excluded tests using computer-aided decision systems and biomarker tests ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"zbGxWo12","properties":{"formattedCitation":"\\super 24\\nosupersub{}","plainCitation":"24","noteIndex":0},"citationItems":[{"id":278,"uris":[""],"uri":[""],"itemData":{"id":278,"type":"article-journal","abstract":"BACKGROUND: Although cardiac risk prediction is widely used in various clinical settings, its potential role in enhancing prehospital triage is yet to be understood.\nOBJECTIVE: To systematically review the diagnostic accuracy of short-term clinical prediction models for potential use in a prehospital population with suspected acute coronary syndrome.\nMETHODS: Eleven electronic medical databases were searched from 1990 to the end of August 2010 for all English-language observational and interventional studies. An online search strategy tool was used to identify grey-literature studies. Eligibility criteria were: 1) an unselected population of adult acute coronary syndrome patients; 2) recruited within the Emergency Department or Emergency Medical Services; 3) reported multivariate analysis encompassing patient history or physical examination; 4) reported short-term outcome measures; 5) were not solely computer protocols; and 6) were not reliant on tests unavailable out of the hospital. Data extraction was conducted by a single reviewer and verified by a second reviewer. Study quality was assessed independently by two reviewers using a validated quality assessment tool.\nRESULTS: A total of seven clinical prediction models were identified. Only two models reported were derived from a prehospital study population. Six clinical prediction models described good discriminate abilities (c-statistic) of 0.72 to 0.87. Among the range of independent predictors identified, electrocardiogram abnormalities, age, heart rate, and systolic blood pressure provided the strongest prognostic information.\nCONCLUSION: The models identified provided reasonable diagnostic accuracy for determining short-term outcomes. Methodological weaknesses and variability in the populations investigated limit their use in clinical practice.","container-title":"The Journal of Emergency Medicine","DOI":"10.1016/j.jemermed.2012.07.078","ISSN":"0736-4679","issue":"5","journalAbbreviation":"J Emerg Med","language":"eng","note":"PMID: 23321296","page":"946-954.e6","source":"PubMed","title":"Diagnostic accuracy of prehospital clinical prediction models to identify short-term outcomes in patients with acute coronary syndromes: a systematic review","title-short":"Diagnostic accuracy of prehospital clinical prediction models to identify short-term outcomes in patients with acute coronary syndromes","volume":"44","author":[{"family":"Nehme","given":"Ziad"},{"family":"Boyle","given":"Malcolm J."},{"family":"Brown","given":"Ted"}],"issued":{"date-parts":[["2013",5]]}}}],"schema":""} 24. With advances in computer technology and point-of-care testing, the use of these components is now increasingly realistic in a pre-hospital setting. The aim of this systematic review was to describe the accuracy of CDSS and their individual components in the pre-hospital management of ACS. METHODThe search strategy followed the guidelines set by the preferred reporting items for systematic review and meta-analysis (PRISMA) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"pt3mJS3c","properties":{"formattedCitation":"\\super 25\\nosupersub{}","plainCitation":"25","noteIndex":0},"citationItems":[{"id":363,"uris":[""],"uri":[""],"itemData":{"id":363,"type":"article-journal","abstract":"Systematic reviews and meta-analyses are essential to summarise evidence relating to efficacy and safety of healthcare interventions accurately and reliably. The clarity and transparency of these reports, however, are not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users.\nSince the development of the QUOROM (quality of reporting of meta-analysis) statement—a reporting guideline published in 1999—there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realising these issues, an international group that included experienced authors and methodologists developed PRISMA (preferred reporting items for systematic reviews and meta-analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions.\nThe PRISMA statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this explanation and elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA statement, this document, and the associated website () should be helpful resources to improve reporting of systematic reviews and meta-analyses.","container-title":"BMJ","DOI":"10.1136/bmj.b2700","ISSN":"0959-8138, 1468-5833","journalAbbreviation":"BMJ","language":"en","note":"PMID: 19622552","page":"b2700","source":"","title":"The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration","title-short":"The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions","volume":"339","author":[{"family":"Liberati","given":"Alessandro"},{"family":"Altman","given":"Douglas G."},{"family":"Tetzlaff","given":"Jennifer"},{"family":"Mulrow","given":"Cynthia"},{"family":"G?tzsche","given":"Peter C."},{"family":"Ioannidis","given":"John P. A."},{"family":"Clarke","given":"Mike"},{"family":"Devereaux","given":"P. J."},{"family":"Kleijnen","given":"Jos"},{"family":"Moher","given":"David"}],"issued":{"date-parts":[["2009",7,21]]}}}],"schema":""} 25. The review protocol was designed with guidance from the PRISMA-Protocol statement and was registered with Prospero (registration number:116600) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"mAUKX8ah","properties":{"formattedCitation":"\\super 26\\nosupersub{}","plainCitation":"26","noteIndex":0},"citationItems":[{"id":376,"uris":[""],"uri":[""],"itemData":{"id":376,"type":"article-journal","abstract":"Systematic reviews should build on a protocol that describes the rationale, hypothesis, and planned methods of the review; few reviews report whether a protocol exists. Detailed, well-described protocols can facilitate the understanding and appraisal of the review methods, as well as the detection of modifications to methods and selective reporting in completed reviews. We describe the development of a reporting guideline, the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015). PRISMA-P consists of a 17-item checklist intended to facilitate the preparation and reporting of a robust protocol for the systematic review. Funders and those commissioning reviews might consider mandating the use of the checklist to facilitate the submission of relevant protocol information in funding applications. Similarly, peer reviewers and editors can use the guidance to gauge the completeness and transparency of a systematic review protocol submitted for publication in a journal or other medium.","container-title":"Systematic Reviews","DOI":"10.1186/2046-4053-4-1","ISSN":"2046-4053","journalAbbreviation":"Syst Rev","language":"eng","note":"PMID: 25554246\nPMCID: PMC4320440","page":"1","source":"PubMed","title":"Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement","volume":"4","author":[{"family":"Moher","given":"David"},{"family":"Shamseer","given":"Larissa"},{"family":"Clarke","given":"Mike"},{"family":"Ghersi","given":"Davina"},{"family":"Liberati","given":"Alessandro"},{"family":"Petticrew","given":"Mark"},{"family":"Shekelle","given":"Paul"},{"family":"Stewart","given":"Lesley A."},{"literal":"PRISMA-P Group"}],"issued":{"date-parts":[["2015",1,1]]}}}],"schema":""} 26.Search strategyThe search strategy was designed and executed by the first author. Five databases were searched: EMBASE, Medline, Cochrane library, Web of Science and CINAHL. The searches were performed between December 2018 and January 2019. Grey literature was also reviewed for any additional sources. The search terms used are in appendix 1. Study selection and eligibilityAbstracts and titles were screened and selected if they were adjudged to be relevant to the review aim. Duplicates were excluded. The review focused on the use of CDSS in a pre-hospital setting where patients presented with symptoms suggestive of ACS. Definitions for ACS included STEMI, NSTEMI or unstable angina as per ESC guidelines ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"VrPi2wgK","properties":{"formattedCitation":"\\super 27\\nosupersub{}","plainCitation":"27","noteIndex":0},"citationItems":[{"id":307,"uris":[""],"uri":[""],"itemData":{"id":307,"type":"article-journal","container-title":"European Heart Journal","DOI":"10.1093/eurheartj/ehy462","ISSN":"1522-9645","journalAbbreviation":"Eur. Heart J.","language":"eng","note":"PMID: 30165617","source":"PubMed","title":"Fourth universal definition of myocardial infarction (2018)","author":[{"family":"Thygesen","given":"Kristian"},{"family":"Alpert","given":"Joseph S."},{"family":"Jaffe","given":"Allan S."},{"family":"Chaitman","given":"Bernard R."},{"family":"Bax","given":"Jeroen J."},{"family":"Morrow","given":"David A."},{"family":"White","given":"Harvey D."},{"literal":"ESC Scientific Document Group"}],"issued":{"date-parts":[["2018",8,25]]}}}],"schema":""} 27. Pre-hospital was defined as contact with first emergency responders (including paramedics, medical dispatch callers, general practitioners). Studies carried out in the hospital environment or emergency department were excluded. Patient history was defined as subjective symptoms reported by the patient (e.g. chest pain, shortness of breath and clamminess), while vital signs/examination were defined as objective non-invasive clinical measurements obtained by clinical staff (e.g. heart rate, blood pressure and oxygen saturations).Inclusion criteria:Published sourceData on patient diagnosis or outcome such as major adverse cardiovascular eventsSet in a pre-hospital settingUse of CDSS as an interventionPatients with suspected ACSEnglish languageExclusion criteriaNo data on outcomesInclusion of emergency department/in-hospital decision aidsInclusion of non-suspected acute coronary syndrome patientsNo definition of Myocardial Infarction (MI)Not in English languageFull-text versions of the papers selected were obtained and analysed. Papers were then included or excluded based on the criteria. A second reviewer judged the selection process and analysed the eligible papers separately by the criteria for consensus. Any disagreements were resolved by discussion between the two reviewers to reach a consensus. Cohen’s kappa co-efficient was performed between the reviewers to analyse the rate of agreement. Assessment of quality and risk of biasQuality assessment was conducted using the QUADAS 2 tool ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"qdrdQNU2","properties":{"formattedCitation":"\\super 28\\nosupersub{}","plainCitation":"28","noteIndex":0},"citationItems":[{"id":475,"uris":[""],"uri":[""],"itemData":{"id":475,"type":"article-journal","abstract":"In 2003, the QUADAS tool for systematic reviews of diagnostic accuracy studies was developed. Experience, anecdotal reports, and feedback suggested areas for improvement; therefore, QUADAS-2 was developed. This tool comprises 4 domains: patient selection, index test, reference standard, and flow and timing. Each domain is assessed in terms of risk of bias, and the first 3 domains are also assessed in terms of concerns regarding applicability. Signalling questions are included to help judge risk of bias. The QUADAS-2 tool is applied in 4 phases: summarize the review question, tailor the tool and produce review-specific guidance, construct a flow diagram for the primary study, and judge bias and applicability. This tool will allow for more transparent rating of bias and applicability of primary diagnostic accuracy studies.","container-title":"Annals of Internal Medicine","DOI":"10.7326/0003-4819-155-8-201110180-00009","ISSN":"1539-3704","issue":"8","journalAbbreviation":"Ann. Intern. Med.","language":"eng","note":"PMID: 22007046","page":"529-536","source":"PubMed","title":"QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies","title-short":"QUADAS-2","volume":"155","author":[{"family":"Whiting","given":"Penny F."},{"family":"Rutjes","given":"Anne W. S."},{"family":"Westwood","given":"Marie E."},{"family":"Mallett","given":"Susan"},{"family":"Deeks","given":"Jonathan J."},{"family":"Reitsma","given":"Johannes B."},{"family":"Leeflang","given":"Mariska M. G."},{"family":"Sterne","given":"Jonathan A. C."},{"family":"Bossuyt","given":"Patrick M. M."},{"literal":"QUADAS-2 Group"}],"issued":{"date-parts":[["2011",10,18]]}}}],"schema":""} 28. Papers were analysed to ensure there was no obvious missing data and that patients progressed through the study as described. Studies were excluded from analysis where there was a high or unclear risk of bias. They were then ranked according to level of evidence as determined by published hierarchy of evidence, which takes into account any validation and impact analysis of CDSS ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"6MW1CMux","properties":{"formattedCitation":"\\super 29\\nosupersub{}","plainCitation":"29","noteIndex":0},"citationItems":[{"id":507,"uris":[""],"uri":[""],"itemData":{"id":507,"type":"chapter","container-title":"Users' Guides to the Medical Literature. A Manual for Evidence-Based Clinical Practice.","edition":"3rd","event-place":"New York","language":"English","page":"407-418","publisher":"McGraw-Hill","publisher-place":"New York","title":"Diagnosis; Clinical Prediction Rules","author":[{"family":"McGinn","given":"Thomas"},{"family":"Wyer","given":"Peter"},{"family":"McCullagh","given":"Lauren"},{"family":"Wisnivesky","given":"Juan"},{"family":"Devereaux","given":"P. J."},{"family":"Stiell","given":"Ian"},{"family":"Richardson","given":"W. Scott"},{"family":"Agoritsas","given":"Thomas"},{"family":"Guyatt","given":"Gordon"}],"accessed":{"date-parts":[["2018",2,19]]},"issued":{"date-parts":[["2015"]]}}}],"schema":""} 29. Data extraction Data were extracted using a data extraction tool that was piloted with two initial studies and subsequently refined. The datatypes that were extracted are outlined in appendix 2. The primary outcome recorded from studies was a final diagnosis of ACS accuracy. Data analysisData analysis was performed using statistical analysis software SPSS 24.0 (SPSS Inc., Chicago, IL). The sensitivity, specificity, positive predictive value and negative predictive value of CDSS were examined. The results were reported as percentages and analysed as continuous data. Whether a history, examination/vital signs, ECG and biomarker components were included in the study, then this was described as binary (yes or no) and treated as categorical data. Independent-samples t-test was used to analyse the difference of mean accuracy (percentage) between CDSS with and without components. A p-value equal to or less than 0.05 was considered to be statistically significant. Because of the considerable heterogeneity between the papers selected, formal meta-analysis was deemed not possible. RESULTSStudy selection and quality assessmentFigure 1 outlines the search and selection process for this review. The titles and abstracts for 11,439 articles were screened. A total of 199 articles were initially identified through this process and reviewed. Of these, 182 articles did not fulfil eligibility criteria, leaving 17. The studies were assessed for their quality using the QUANDAS 2 tool ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"h74plOnW","properties":{"formattedCitation":"\\super 28\\nosupersub{}","plainCitation":"28","noteIndex":0},"citationItems":[{"id":475,"uris":[""],"uri":[""],"itemData":{"id":475,"type":"article-journal","abstract":"In 2003, the QUADAS tool for systematic reviews of diagnostic accuracy studies was developed. Experience, anecdotal reports, and feedback suggested areas for improvement; therefore, QUADAS-2 was developed. This tool comprises 4 domains: patient selection, index test, reference standard, and flow and timing. Each domain is assessed in terms of risk of bias, and the first 3 domains are also assessed in terms of concerns regarding applicability. Signalling questions are included to help judge risk of bias. The QUADAS-2 tool is applied in 4 phases: summarize the review question, tailor the tool and produce review-specific guidance, construct a flow diagram for the primary study, and judge bias and applicability. This tool will allow for more transparent rating of bias and applicability of primary diagnostic accuracy studies.","container-title":"Annals of Internal Medicine","DOI":"10.7326/0003-4819-155-8-201110180-00009","ISSN":"1539-3704","issue":"8","journalAbbreviation":"Ann. Intern. Med.","language":"eng","note":"PMID: 22007046","page":"529-536","source":"PubMed","title":"QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies","title-short":"QUADAS-2","volume":"155","author":[{"family":"Whiting","given":"Penny F."},{"family":"Rutjes","given":"Anne W. S."},{"family":"Westwood","given":"Marie E."},{"family":"Mallett","given":"Susan"},{"family":"Deeks","given":"Jonathan J."},{"family":"Reitsma","given":"Johannes B."},{"family":"Leeflang","given":"Mariska M. G."},{"family":"Sterne","given":"Jonathan A. C."},{"family":"Bossuyt","given":"Patrick M. M."},{"literal":"QUADAS-2 Group"}],"issued":{"date-parts":[["2011",10,18]]}}}],"schema":""} 28. Four studies were rejected from the study due to high risk of bias. A further five studies were assessed to have some minimal or moderate bias, all with patient selection, as would be expected with non-randomised prospective and observational studies ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"38ziGyIy","properties":{"formattedCitation":"\\super 20,30\\uc0\\u8211{}33\\nosupersub{}","plainCitation":"20,30–33","noteIndex":0},"citationItems":[{"id":441,"uris":[""],"uri":[""],"itemData":{"id":441,"type":"article-journal","abstract":"BACKGROUND: To evaluate whether a computer-based decision support system could improve the allocation of patients with acute coronary syndrome (ACS) or a life-threatening condition (LTC). We hypothesised that a system of this kind would improve sensitivity without compromising specificity.\nMETHODS: A total of 2285 consecutive patients who dialed 112 due to chest pain were asked 10 specific questions and a prediction model was constructed based on the answers. We compared the sensitivity of the dispatchers' decisions with that of the model-based decision support model.\nRESULTS: A total of 2048 patients answered all 10 questions. Among the 235 patients with ACS, 194 were allocated the highest prioritisation by dispatchers (sensitivity 82.6%) and 41 patients were given a lower prioritisation (17.4% false negatives). The allocation suggested by the model used the highest prioritisation in 212 of the patients with ACS (sensitivity of 90.2%), while 23 patients were underprioritised (9.8% false negatives). The results were similar when the two systems were compared with regard to LTC and 30-day mortality. This indicates that computer-based decision support could be used either for increasing sensitivity or for saving resources. Three questions proved to be most important in terms of predicting ACS/LTC, [1] the intensity of pain, [2] the localisation of pain and [3] a history of ACS.\nCONCLUSION: Among patients with acute chest pain, computer-based decision support with a model based on a few fundamental questions could improve sensitivity and reduce the number of cases with the highest prioritisation without endangering the patients.","container-title":"International Journal of Cardiology","DOI":"10.1016/j.ijcard.2016.06.281","ISSN":"1874-1754","journalAbbreviation":"Int. J. Cardiol.","language":"eng","note":"PMID: 27393857","page":"734-738","source":"PubMed","title":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support? A cohort of patients with chest pain","title-short":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support?","volume":"220","author":[{"family":"Gellerstedt","given":"Martin"},{"family":"Rawshani","given":"Nina"},{"family":"Herlitz","given":"Johan"},{"family":"B?ng","given":"Angela"},{"family":"Gelang","given":"Carita"},{"family":"Andersson","given":"Jan-Otto"},{"family":"Larsson","given":"Anna"},{"family":"Rawshani","given":"Araz"}],"issued":{"date-parts":[["2016",10,1]]}}},{"id":445,"uris":[""],"uri":[""],"itemData":{"id":445,"type":"article-journal","abstract":"BACKGROUND: Identifying ST-segment elevation myocardial infarctions (STEMIs) in the field can decrease door-to-balloon times. Paramedics may use a computer algorithm to help them interpret prehospital electrocariograms (ECGs). It is unknown how accurately the computer can identify STEMIs.\nOBJECTIVES: To Determine the sensitivity and specificity of prehospital ECGs in identifying patients with STEMI.\nMETHODS: Retrospective cross-sectional study of 200 prehospital ECGs acquired using Lifepak 12 monitors and transmitted by one of more than 20 emergency medical services (EMS) agencies to the emergency department (ED) of a Summa Akron City Hospital, a level 1 trauma center between January 1, 2007, and February 18, 2010. The ED sees more than 73,000 adult patients and treats 120 STEMIs annually. The laboratory performs 3,400 catheterizations annually. The first 100 patients with a diagnosis of STEMI and cardiac catheterization laboratory activation from the ED were analyzed. For comparison, a control group of 100 other ECGs from patients without a STEMI were randomly selected from our Medtronic database using a random-number generator. For patients with STEMI, an accurate computer interpretation was \"acute MI suspected.\" Other interpretations were counted as misses. Specificity and sensitivity were calculated with confidence intervals (CIs). The sample size was determined a priori for a 95% CI of ±10%.\nRESULTS: Zero control patients were incorrectly labeled \"acute MI suspected.\" The specificity was 100% (100/100; 95% CI 0.96-1.0), whereas the sensitivity was 58% (58/100; 95% CI 0.48-0.67). This would have resulted in 42 missed cardiac catheterization laboratory activations, but zero inappropriate activations. The most common incorrect interpretation of STEMI ECGs by the computer was \"data quality prohibits interpretation,\" followed by \"abnormal ECG unconfirmed.\"\nCONCLUSIONS: Prehospital computer interpretation is not sensitive for STEMI identification and should not be used as a single method for prehospital activation of the cardiac catheterizing laboratory. Because of its high specificity, it may serve as an adjunct to interpretation.","container-title":"Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors","DOI":"10.3109/10903127.2012.722176","ISSN":"1545-0066","issue":"2","journalAbbreviation":"Prehosp Emerg Care","language":"eng","note":"PMID: 23066910","page":"211-216","source":"PubMed","title":"Prehospital electrocardiographic computer identification of ST-segment elevation myocardial infarction","volume":"17","author":[{"family":"Bhalla","given":"Mary Colleen"},{"family":"Mencl","given":"Francis"},{"family":"Gist","given":"Mikki Amber"},{"family":"Wilber","given":"Scott"},{"family":"Zalewski","given":"Jon"}],"issued":{"date-parts":[["2013",6]]}}},{"id":437,"uris":[""],"uri":[""],"itemData":{"id":437,"type":"article-journal","abstract":"BACKGROUND: The purposes of this study were to create a new flow-chart of prehospital electrocardiography (ECG)-transmission, evaluate its predictive ability for ST-elevation myocardial infarction (STEMI) and shorten door-to-balloon time (DTBT).\nMETHOD AND RESULTS: The new transmission flow-chart was created using symptoms from previous medical records of STEMI patients. A total of 4090 consecutive patients transferred emergently to our hospital were divided into two groups: those in ambulances with an ECG-transmission device with the new flow-chart (ECGT-FC) and those transferred without an ECG-transmission device (non-ECGT) groups. A STEMI group comprising walk-in patients during the same period was used as a control group. The predictive ability of STEMI and the effectiveness of shortening the DTBT by the new flow-chart of ECG-transmission was evaluated. In the ECGT-FC group, the prevalence of STEMI in the ECG-transmission by the new flow-chart were significantly higher than in the non-ECG-transmission patients (6.71% vs. 0.19%; p<0.001). The sensitivity and specificity of the new ECG-transmission flow-chart were 83.3% and 88.1%, respectively. The median DTBT was significantly shortened (p=0.045) and the prevalence of DTBT<90min was significantly higher in the ECGT-FC group (p=0.018) than the other groups.\nCONCLUSION: The sensitivity and specificity of the new flow-chart for ECG-transmission were high. The new flow-chart combined with an ECG-transmission device could detect STEMI efficiently and shorten DTBT.","container-title":"Journal of Cardiology","DOI":"10.1016/j.jjcc.2018.03.011","ISSN":"1876-4738","issue":"4","journalAbbreviation":"J Cardiol","language":"eng","note":"PMID: 29804908","page":"335-342","source":"PubMed","title":"Predictive ability and efficacy for shortening door-to-balloon time of a new prehospital electrocardiogram-transmission flow chart in patients with ST-elevation myocardial infarction - Results of the CASSIOPEIA study","volume":"72","author":[{"family":"Sakai","given":"Toshiaki"},{"family":"Nishiyama","given":"Osamu"},{"family":"Onodera","given":"Masayuki"},{"family":"Matsuda","given":"Shigekatsu"},{"family":"Wakisawa","given":"Shinobu"},{"family":"Nakamura","given":"Motoyuki"},{"family":"Morino","given":"Yoshihiro"},{"family":"Itoh","given":"Tomonori"},{"literal":"CASSIOPEIA study group"}],"issued":{"date-parts":[["2018",10]]}}},{"id":447,"uris":[""],"uri":[""],"itemData":{"id":447,"type":"article-journal","abstract":"BACKGROUND: Diagnosing acute coronary syndrome (ACS) in a primary care setting poses a diagnostic dilemma for physicians.\nOBJECTIVE: We directly compared the diagnostic accuracy of a clinical decision rule (CDR) based on history taking and physical examination in suspected ACS with the risk estimates of the attending GP.\nMETHODS: In a prospective multicenter study, patients suspected of ACS were included by the GP. GPs were asked to estimate the probability (0%-100%) of the presence of ACS. GPs collected patient data, but they were not aware of the CDR and did not score the patient accordingly.\nRESULTS: Two hundred and ninety-eight patients were included (52% female, mean age 66 years, 22% ACS). The area under the receiver operating characteristic (ROC) curve (AUC) was 0.75 [95% confidence interval (CI) 0.68-0.82] for the GP risk estimate and 0.66 (95% CI 0.58-0.73) for the CDR. There was an agreement between the risk estimation of the GP and a CDR in 51% and the prevalence of ACS in predefined low-, intermediate- and high-risk groups was similar for the GP and CDR estimates. In the low-risk group, according to the GP, four patients (8.2%) suffered an ACS. These four patients were all identified by the decision rule as high risk.\nCONCLUSIONS: The GP classified patients as ACS or no ACS more adequately than the CDR, judged by the AUC. However, the use of a CDR in patients that are considered at low risk for ACS by the GP could reduce the amount of missed myocardial infarctions.","container-title":"Family Practice","DOI":"10.1093/fampra/cmq116","ISSN":"1460-2229","issue":"3","journalAbbreviation":"Fam Pract","language":"eng","note":"PMID: 21239470","page":"323-328","source":"PubMed","title":"Diagnosing acute coronary syndrome in primary care: comparison of the physicians' risk estimation and a clinical decision rule","title-short":"Diagnosing acute coronary syndrome in primary care","volume":"28","author":[{"family":"Bruins Slot","given":"M. H. E."},{"family":"Rutten","given":"F. H."},{"family":"Heijden","given":"G. J. M. G.","non-dropping-particle":"van der"},{"family":"Geersing","given":"G. J."},{"family":"Glatz","given":"J. F. C."},{"family":"Hoes","given":"A. W."}],"issued":{"date-parts":[["2011",6]]}}},{"id":478,"uris":[""],"uri":[""],"itemData":{"id":478,"type":"article-journal","abstract":"OBJECTIVE: To improve pre-hospital triage of patients with suspected acute cardiac disease.\nDESIGN: Prospective study. SUBJECTS. Patients with symptoms suggestive of acute cardiac pathology, who were seen by a general practitioner, for whom acute admission into hospital was requested, and in whom a pre-hospital electrocardiogram was recorded by the ambulance service.\nMETHODS: The study consisted of two phases. In the first phase, a decision rule was developed based on clinical characteristics and electrocardiographic findings in 1005 patients with suspected acute cardiac pathology. In the second phase, the decision rule was prospectively validated. Symptoms were recorded by a standardized questionnaire by the general practitioner and a computerized electrocardiogram was made by the ambulance nurses at the patient's home. Three electrocardiographic outcomes were available: 'normal electrocardiogram', 'possible myocardial infarction' or 'extensive myocardial infarction'. By use of the predictive model, the general practitioner could decide if hospitalization was necessary or not.\nMAIN OUTCOME MEASUREMENTS: Identification of patients at low (stable angina, atypical chest pain, other pathology) and high (myocardial infarction, unstable angina) probability of acute cardiac pathology.\nRESULTS: Among 977 patients with a complete pre-hospital evaluation in the validation phase of the study, the decision rule recommended 'no hospitalization' in 227 patients (23%). The general practitioner followed this advice in 44% of these patients. Although seven of them developed a non-Q wave myocardial infarction, no complications occurred in patients not admitted. In addition, the general practitioner did not hospitalize 19 (2%) of 750 patients for whom the decision rule recommended admission. Pre-hospital triage by the general practitioner resulted in a 12% (118 of 977 patients) reduction of the number of patients admitted to the Coronary Care Units.\nCONCLUSIONS: Pre-hospital triage by the general practitioner was facilitated using a standardized questionnaire and pre-hospital electrocardiography, and resulted in a reduction in the number of patients admitted to the Coronary Care Unit, and proved to be safe.","container-title":"European Heart Journal","ISSN":"0195-668X","issue":"1","journalAbbreviation":"Eur. Heart J.","language":"eng","note":"PMID: 8682136","page":"89-95","source":"PubMed","title":"Implementation of a pre-hospital decision rule in general practice. Triage of patients with suspected myocardial infarction","volume":"17","author":[{"family":"Grijseels","given":"E. W."},{"family":"Deckers","given":"J. W."},{"family":"Hoes","given":"A. W."},{"family":"Boersma","given":"E."},{"family":"Hartman","given":"J. A."},{"family":"Does","given":"E.","non-dropping-particle":"van der"},{"family":"Simoons","given":"M. L."}],"issued":{"date-parts":[["1996",1]]}}}],"schema":""} 20,30–33. Only two studies had validation phases for their CDSS and there was no impact analysis with any of the 17 articles thus undermining of the potential quality of evidence as judged by the pre-defined hierarchy ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"FbvMVqOv","properties":{"formattedCitation":"\\super 31,33\\nosupersub{}","plainCitation":"31,33","noteIndex":0},"citationItems":[{"id":437,"uris":[""],"uri":[""],"itemData":{"id":437,"type":"article-journal","abstract":"BACKGROUND: The purposes of this study were to create a new flow-chart of prehospital electrocardiography (ECG)-transmission, evaluate its predictive ability for ST-elevation myocardial infarction (STEMI) and shorten door-to-balloon time (DTBT).\nMETHOD AND RESULTS: The new transmission flow-chart was created using symptoms from previous medical records of STEMI patients. A total of 4090 consecutive patients transferred emergently to our hospital were divided into two groups: those in ambulances with an ECG-transmission device with the new flow-chart (ECGT-FC) and those transferred without an ECG-transmission device (non-ECGT) groups. A STEMI group comprising walk-in patients during the same period was used as a control group. The predictive ability of STEMI and the effectiveness of shortening the DTBT by the new flow-chart of ECG-transmission was evaluated. In the ECGT-FC group, the prevalence of STEMI in the ECG-transmission by the new flow-chart were significantly higher than in the non-ECG-transmission patients (6.71% vs. 0.19%; p<0.001). The sensitivity and specificity of the new ECG-transmission flow-chart were 83.3% and 88.1%, respectively. The median DTBT was significantly shortened (p=0.045) and the prevalence of DTBT<90min was significantly higher in the ECGT-FC group (p=0.018) than the other groups.\nCONCLUSION: The sensitivity and specificity of the new flow-chart for ECG-transmission were high. The new flow-chart combined with an ECG-transmission device could detect STEMI efficiently and shorten DTBT.","container-title":"Journal of Cardiology","DOI":"10.1016/j.jjcc.2018.03.011","ISSN":"1876-4738","issue":"4","journalAbbreviation":"J Cardiol","language":"eng","note":"PMID: 29804908","page":"335-342","source":"PubMed","title":"Predictive ability and efficacy for shortening door-to-balloon time of a new prehospital electrocardiogram-transmission flow chart in patients with ST-elevation myocardial infarction - Results of the CASSIOPEIA study","volume":"72","author":[{"family":"Sakai","given":"Toshiaki"},{"family":"Nishiyama","given":"Osamu"},{"family":"Onodera","given":"Masayuki"},{"family":"Matsuda","given":"Shigekatsu"},{"family":"Wakisawa","given":"Shinobu"},{"family":"Nakamura","given":"Motoyuki"},{"family":"Morino","given":"Yoshihiro"},{"family":"Itoh","given":"Tomonori"},{"literal":"CASSIOPEIA study group"}],"issued":{"date-parts":[["2018",10]]}}},{"id":478,"uris":[""],"uri":[""],"itemData":{"id":478,"type":"article-journal","abstract":"OBJECTIVE: To improve pre-hospital triage of patients with suspected acute cardiac disease.\nDESIGN: Prospective study. SUBJECTS. Patients with symptoms suggestive of acute cardiac pathology, who were seen by a general practitioner, for whom acute admission into hospital was requested, and in whom a pre-hospital electrocardiogram was recorded by the ambulance service.\nMETHODS: The study consisted of two phases. In the first phase, a decision rule was developed based on clinical characteristics and electrocardiographic findings in 1005 patients with suspected acute cardiac pathology. In the second phase, the decision rule was prospectively validated. Symptoms were recorded by a standardized questionnaire by the general practitioner and a computerized electrocardiogram was made by the ambulance nurses at the patient's home. Three electrocardiographic outcomes were available: 'normal electrocardiogram', 'possible myocardial infarction' or 'extensive myocardial infarction'. By use of the predictive model, the general practitioner could decide if hospitalization was necessary or not.\nMAIN OUTCOME MEASUREMENTS: Identification of patients at low (stable angina, atypical chest pain, other pathology) and high (myocardial infarction, unstable angina) probability of acute cardiac pathology.\nRESULTS: Among 977 patients with a complete pre-hospital evaluation in the validation phase of the study, the decision rule recommended 'no hospitalization' in 227 patients (23%). The general practitioner followed this advice in 44% of these patients. Although seven of them developed a non-Q wave myocardial infarction, no complications occurred in patients not admitted. In addition, the general practitioner did not hospitalize 19 (2%) of 750 patients for whom the decision rule recommended admission. Pre-hospital triage by the general practitioner resulted in a 12% (118 of 977 patients) reduction of the number of patients admitted to the Coronary Care Units.\nCONCLUSIONS: Pre-hospital triage by the general practitioner was facilitated using a standardized questionnaire and pre-hospital electrocardiography, and resulted in a reduction in the number of patients admitted to the Coronary Care Unit, and proved to be safe.","container-title":"European Heart Journal","ISSN":"0195-668X","issue":"1","journalAbbreviation":"Eur. Heart J.","language":"eng","note":"PMID: 8682136","page":"89-95","source":"PubMed","title":"Implementation of a pre-hospital decision rule in general practice. Triage of patients with suspected myocardial infarction","volume":"17","author":[{"family":"Grijseels","given":"E. W."},{"family":"Deckers","given":"J. W."},{"family":"Hoes","given":"A. W."},{"family":"Boersma","given":"E."},{"family":"Hartman","given":"J. A."},{"family":"Does","given":"E.","non-dropping-particle":"van der"},{"family":"Simoons","given":"M. L."}],"issued":{"date-parts":[["1996",1]]}}}],"schema":""} 31,33. Ideally, validation and impact analysis would be required before any CDSS could be judged suitable for implementation in other health localities. The second reviewer screened the 17 selected studies and Cohens kappa coefficient for inter-observer agreement between the two reviewers was calculated at k=0.46, which equates to moderate agreement. Following collaboration with the second reviewer and QUANDAS 2 tool quality control, nine studies from the 17 were excluded, leaving eight studies that were included in the analysis ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"VYFQ63G6","properties":{"formattedCitation":"\\super 16,20,30\\uc0\\u8211{}35\\nosupersub{}","plainCitation":"16,20,30–35","noteIndex":0},"citationItems":[{"id":441,"uris":[""],"uri":[""],"itemData":{"id":441,"type":"article-journal","abstract":"BACKGROUND: To evaluate whether a computer-based decision support system could improve the allocation of patients with acute coronary syndrome (ACS) or a life-threatening condition (LTC). We hypothesised that a system of this kind would improve sensitivity without compromising specificity.\nMETHODS: A total of 2285 consecutive patients who dialed 112 due to chest pain were asked 10 specific questions and a prediction model was constructed based on the answers. We compared the sensitivity of the dispatchers' decisions with that of the model-based decision support model.\nRESULTS: A total of 2048 patients answered all 10 questions. Among the 235 patients with ACS, 194 were allocated the highest prioritisation by dispatchers (sensitivity 82.6%) and 41 patients were given a lower prioritisation (17.4% false negatives). The allocation suggested by the model used the highest prioritisation in 212 of the patients with ACS (sensitivity of 90.2%), while 23 patients were underprioritised (9.8% false negatives). The results were similar when the two systems were compared with regard to LTC and 30-day mortality. This indicates that computer-based decision support could be used either for increasing sensitivity or for saving resources. Three questions proved to be most important in terms of predicting ACS/LTC, [1] the intensity of pain, [2] the localisation of pain and [3] a history of ACS.\nCONCLUSION: Among patients with acute chest pain, computer-based decision support with a model based on a few fundamental questions could improve sensitivity and reduce the number of cases with the highest prioritisation without endangering the patients.","container-title":"International Journal of Cardiology","DOI":"10.1016/j.ijcard.2016.06.281","ISSN":"1874-1754","journalAbbreviation":"Int. J. Cardiol.","language":"eng","note":"PMID: 27393857","page":"734-738","source":"PubMed","title":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support? A cohort of patients with chest pain","title-short":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support?","volume":"220","author":[{"family":"Gellerstedt","given":"Martin"},{"family":"Rawshani","given":"Nina"},{"family":"Herlitz","given":"Johan"},{"family":"B?ng","given":"Angela"},{"family":"Gelang","given":"Carita"},{"family":"Andersson","given":"Jan-Otto"},{"family":"Larsson","given":"Anna"},{"family":"Rawshani","given":"Araz"}],"issued":{"date-parts":[["2016",10,1]]}}},{"id":220,"uris":[""],"uri":[""],"itemData":{"id":220,"type":"article-journal","abstract":"OBJECTIVE: ST-elevation myocardial infarction (STEMI) identification by emergency medicine services (EMS) leading to pre-hospital catheterization laboratory (CL) activation shortens ischemic time and improves outcomes. We examined the incremental value of addition of a screening clinical tool (CT), containing clinical information and a Zoll electrocardiogram (ECG)-resident STEMI identification program (ZI) to ZI alone.\nMETHODS: All EMS-performed and ZI-analyzed ECGs transmitted to a percutaneous coronary intervention hospital from October 2009 to January 2011 were reviewed for diagnostic accuracy. ZI performance was also compared to ECG interpretations by 2 experienced readers The CT was then retrospectively applied to determine the incremental benefit above the ZI alone.\nRESULTS: ST-elevation myocardial infarction was confirmed in 23 (7.5%) of 305 patients. ZI was positive in 37 (12.1%): sensitivity: 95.6% and specificity: 94.6%, positive predictive value (PPV), 59.5%, negative predictive value (NPV), 99.6%, and accuracy of 93.8%. Moderate agreement was observed among the readers and ZI. CT criteria for CL activation were met in 24 (7.8%): 20 (83.3%) were confirmed STEMIs: sensitivity: 86.9%, specificity: 98.5%, a PPV: 83.3%, and NPV: 98.6%, accuracy of 97.7%. CT + ZI increased PPV (P<0.05) and specificity (P<0.003) by reducing false positive STEMI identifications from 15 (4.9%) to 4 (1.3%).\nCONCLUSIONS: In an urban cohort of all EMS transmitted ECGs, ZI has high sensitivity and specificity for STEMI identification. Whereas the PPV was low, reflecting both low STEMI prevalence and presence of STEMI-mimics, the NPV was very high. These findings suggest that a simplified CT combined with computer STEMI interpretation can identify patients for pre-hospital CL activation. Confirmation of these results could improve the design of STEMI care systems.","container-title":"The American Journal of Emergency Medicine","DOI":"10.1016/j.ajem.2013.04.013","ISSN":"1532-8171","issue":"7","journalAbbreviation":"Am J Emerg Med","language":"eng","note":"PMID: 23706572","page":"1098-1102","source":"PubMed","title":"An algorithm for identification of ST-elevation myocardial infarction patients by emergency medicine services","volume":"31","author":[{"family":"Wilson","given":"Ryan E."},{"family":"Kado","given":"Herman S."},{"family":"Percy","given":"Robert F."},{"family":"Butterfield","given":"Ryan C."},{"family":"Sabato","given":"Joseph"},{"family":"Strom","given":"Joel A."},{"family":"Box","given":"Lyndon C."}],"issued":{"date-parts":[["2013",7]]}}},{"id":445,"uris":[""],"uri":[""],"itemData":{"id":445,"type":"article-journal","abstract":"BACKGROUND: Identifying ST-segment elevation myocardial infarctions (STEMIs) in the field can decrease door-to-balloon times. Paramedics may use a computer algorithm to help them interpret prehospital electrocariograms (ECGs). It is unknown how accurately the computer can identify STEMIs.\nOBJECTIVES: To Determine the sensitivity and specificity of prehospital ECGs in identifying patients with STEMI.\nMETHODS: Retrospective cross-sectional study of 200 prehospital ECGs acquired using Lifepak 12 monitors and transmitted by one of more than 20 emergency medical services (EMS) agencies to the emergency department (ED) of a Summa Akron City Hospital, a level 1 trauma center between January 1, 2007, and February 18, 2010. The ED sees more than 73,000 adult patients and treats 120 STEMIs annually. The laboratory performs 3,400 catheterizations annually. The first 100 patients with a diagnosis of STEMI and cardiac catheterization laboratory activation from the ED were analyzed. For comparison, a control group of 100 other ECGs from patients without a STEMI were randomly selected from our Medtronic database using a random-number generator. For patients with STEMI, an accurate computer interpretation was \"acute MI suspected.\" Other interpretations were counted as misses. Specificity and sensitivity were calculated with confidence intervals (CIs). The sample size was determined a priori for a 95% CI of ±10%.\nRESULTS: Zero control patients were incorrectly labeled \"acute MI suspected.\" The specificity was 100% (100/100; 95% CI 0.96-1.0), whereas the sensitivity was 58% (58/100; 95% CI 0.48-0.67). This would have resulted in 42 missed cardiac catheterization laboratory activations, but zero inappropriate activations. The most common incorrect interpretation of STEMI ECGs by the computer was \"data quality prohibits interpretation,\" followed by \"abnormal ECG unconfirmed.\"\nCONCLUSIONS: Prehospital computer interpretation is not sensitive for STEMI identification and should not be used as a single method for prehospital activation of the cardiac catheterizing laboratory. Because of its high specificity, it may serve as an adjunct to interpretation.","container-title":"Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors","DOI":"10.3109/10903127.2012.722176","ISSN":"1545-0066","issue":"2","journalAbbreviation":"Prehosp Emerg Care","language":"eng","note":"PMID: 23066910","page":"211-216","source":"PubMed","title":"Prehospital electrocardiographic computer identification of ST-segment elevation myocardial infarction","volume":"17","author":[{"family":"Bhalla","given":"Mary Colleen"},{"family":"Mencl","given":"Francis"},{"family":"Gist","given":"Mikki Amber"},{"family":"Wilber","given":"Scott"},{"family":"Zalewski","given":"Jon"}],"issued":{"date-parts":[["2013",6]]}}},{"id":439,"uris":[""],"uri":[""],"itemData":{"id":439,"type":"article-journal","abstract":"BACKGROUND: The first study of the FamouS Triage project investigates the feasibility of ruling out a myocardial infarction in pre-hospital chest pain patients without electrocardiographic ST-segment elevation by using the modified HEART score at the patient's home, incorporating only a single highly sensitive troponin T measurement.\nMETHODS: A venous blood sample was drawn in the ambulance from 1127 consecutive chest pain patients for measurement of the pre-hospital highly sensitive troponin T levels, in order to establish a pre-hospital HEART score (i.e. the modified HEART score) and evaluate the possibility of triage at the patient's home. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) i.e. acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or death within 30 days after initial presentation.\nRESULTS: Two hundred and six patients (18%) developed a MACE during 30 days of follow-up. Thirty-six per cent of the patients ( n=403) had a low modified HEART score (0-3 points) and none of them developed a MACE during follow-up. Forty-four per cent of the patients ( n=494) had an intermediate modified HEART score (4-6 points) and 18% of them developed a MACE. Twenty per cent of the patients ( n=230) had a high modified HEART score (7-10 points) of which 52% developed a MACE during follow-up.\nCONCLUSION: It seems feasible to rule out a myocardial infarction at home in chest pain patients without ST-segment elevation by using the modified HEART score.\nTRIAL ID: NTR4205. Dutch Trial Register [ ]: trial number 4205.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872616687116","ISSN":"2048-8734","issue":"2","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 28084079","page":"102-110","source":"PubMed","title":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score","title-short":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage)","volume":"7","author":[{"family":"Ishak","given":"Maycel"},{"family":"Ali","given":"Danish"},{"family":"Fokkert","given":"Marion J."},{"family":"Slingerland","given":"Robbert J."},{"family":"Tolsma","given":"Rudolf T."},{"family":"Badings","given":"Erik"},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Eenennaam","given":"Fred","non-dropping-particle":"van"},{"family":"Mosterd","given":"Arend"},{"family":"Ten Berg","given":"Jurri?n M."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"}],"issued":{"date-parts":[["2018",3]]}}},{"id":437,"uris":[""],"uri":[""],"itemData":{"id":437,"type":"article-journal","abstract":"BACKGROUND: The purposes of this study were to create a new flow-chart of prehospital electrocardiography (ECG)-transmission, evaluate its predictive ability for ST-elevation myocardial infarction (STEMI) and shorten door-to-balloon time (DTBT).\nMETHOD AND RESULTS: The new transmission flow-chart was created using symptoms from previous medical records of STEMI patients. A total of 4090 consecutive patients transferred emergently to our hospital were divided into two groups: those in ambulances with an ECG-transmission device with the new flow-chart (ECGT-FC) and those transferred without an ECG-transmission device (non-ECGT) groups. A STEMI group comprising walk-in patients during the same period was used as a control group. The predictive ability of STEMI and the effectiveness of shortening the DTBT by the new flow-chart of ECG-transmission was evaluated. In the ECGT-FC group, the prevalence of STEMI in the ECG-transmission by the new flow-chart were significantly higher than in the non-ECG-transmission patients (6.71% vs. 0.19%; p<0.001). The sensitivity and specificity of the new ECG-transmission flow-chart were 83.3% and 88.1%, respectively. The median DTBT was significantly shortened (p=0.045) and the prevalence of DTBT<90min was significantly higher in the ECGT-FC group (p=0.018) than the other groups.\nCONCLUSION: The sensitivity and specificity of the new flow-chart for ECG-transmission were high. The new flow-chart combined with an ECG-transmission device could detect STEMI efficiently and shorten DTBT.","container-title":"Journal of Cardiology","DOI":"10.1016/j.jjcc.2018.03.011","ISSN":"1876-4738","issue":"4","journalAbbreviation":"J Cardiol","language":"eng","note":"PMID: 29804908","page":"335-342","source":"PubMed","title":"Predictive ability and efficacy for shortening door-to-balloon time of a new prehospital electrocardiogram-transmission flow chart in patients with ST-elevation myocardial infarction - Results of the CASSIOPEIA study","volume":"72","author":[{"family":"Sakai","given":"Toshiaki"},{"family":"Nishiyama","given":"Osamu"},{"family":"Onodera","given":"Masayuki"},{"family":"Matsuda","given":"Shigekatsu"},{"family":"Wakisawa","given":"Shinobu"},{"family":"Nakamura","given":"Motoyuki"},{"family":"Morino","given":"Yoshihiro"},{"family":"Itoh","given":"Tomonori"},{"literal":"CASSIOPEIA study group"}],"issued":{"date-parts":[["2018",10]]}}},{"id":447,"uris":[""],"uri":[""],"itemData":{"id":447,"type":"article-journal","abstract":"BACKGROUND: Diagnosing acute coronary syndrome (ACS) in a primary care setting poses a diagnostic dilemma for physicians.\nOBJECTIVE: We directly compared the diagnostic accuracy of a clinical decision rule (CDR) based on history taking and physical examination in suspected ACS with the risk estimates of the attending GP.\nMETHODS: In a prospective multicenter study, patients suspected of ACS were included by the GP. GPs were asked to estimate the probability (0%-100%) of the presence of ACS. GPs collected patient data, but they were not aware of the CDR and did not score the patient accordingly.\nRESULTS: Two hundred and ninety-eight patients were included (52% female, mean age 66 years, 22% ACS). The area under the receiver operating characteristic (ROC) curve (AUC) was 0.75 [95% confidence interval (CI) 0.68-0.82] for the GP risk estimate and 0.66 (95% CI 0.58-0.73) for the CDR. There was an agreement between the risk estimation of the GP and a CDR in 51% and the prevalence of ACS in predefined low-, intermediate- and high-risk groups was similar for the GP and CDR estimates. In the low-risk group, according to the GP, four patients (8.2%) suffered an ACS. These four patients were all identified by the decision rule as high risk.\nCONCLUSIONS: The GP classified patients as ACS or no ACS more adequately than the CDR, judged by the AUC. However, the use of a CDR in patients that are considered at low risk for ACS by the GP could reduce the amount of missed myocardial infarctions.","container-title":"Family Practice","DOI":"10.1093/fampra/cmq116","ISSN":"1460-2229","issue":"3","journalAbbreviation":"Fam Pract","language":"eng","note":"PMID: 21239470","page":"323-328","source":"PubMed","title":"Diagnosing acute coronary syndrome in primary care: comparison of the physicians' risk estimation and a clinical decision rule","title-short":"Diagnosing acute coronary syndrome in primary care","volume":"28","author":[{"family":"Bruins Slot","given":"M. H. E."},{"family":"Rutten","given":"F. H."},{"family":"Heijden","given":"G. J. M. G.","non-dropping-particle":"van der"},{"family":"Geersing","given":"G. J."},{"family":"Glatz","given":"J. F. C."},{"family":"Hoes","given":"A. W."}],"issued":{"date-parts":[["2011",6]]}}},{"id":435,"uris":[""],"uri":[""],"itemData":{"id":435,"type":"article-journal","abstract":"BACKGROUND:: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE).\nMETHODS:: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ? 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death.\nRESULTS:: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%).\nCONCLUSIONS:: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872618813846","ISSN":"2048-8734","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 30468395","page":"2048872618813846","source":"PubMed","title":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study","title-short":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome","author":[{"family":"Dongen","given":"Dominique N.","non-dropping-particle":"van"},{"family":"Tolsma","given":"Rudolf T."},{"family":"Fokkert","given":"Marion J."},{"family":"Badings","given":"Erik A."},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Slingerland","given":"Robbert J."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"},{"family":"Ottervanger","given":"Jan Paul"}],"issued":{"date-parts":[["2018",11,23]]}}},{"id":478,"uris":[""],"uri":[""],"itemData":{"id":478,"type":"article-journal","abstract":"OBJECTIVE: To improve pre-hospital triage of patients with suspected acute cardiac disease.\nDESIGN: Prospective study. SUBJECTS. Patients with symptoms suggestive of acute cardiac pathology, who were seen by a general practitioner, for whom acute admission into hospital was requested, and in whom a pre-hospital electrocardiogram was recorded by the ambulance service.\nMETHODS: The study consisted of two phases. In the first phase, a decision rule was developed based on clinical characteristics and electrocardiographic findings in 1005 patients with suspected acute cardiac pathology. In the second phase, the decision rule was prospectively validated. Symptoms were recorded by a standardized questionnaire by the general practitioner and a computerized electrocardiogram was made by the ambulance nurses at the patient's home. Three electrocardiographic outcomes were available: 'normal electrocardiogram', 'possible myocardial infarction' or 'extensive myocardial infarction'. By use of the predictive model, the general practitioner could decide if hospitalization was necessary or not.\nMAIN OUTCOME MEASUREMENTS: Identification of patients at low (stable angina, atypical chest pain, other pathology) and high (myocardial infarction, unstable angina) probability of acute cardiac pathology.\nRESULTS: Among 977 patients with a complete pre-hospital evaluation in the validation phase of the study, the decision rule recommended 'no hospitalization' in 227 patients (23%). The general practitioner followed this advice in 44% of these patients. Although seven of them developed a non-Q wave myocardial infarction, no complications occurred in patients not admitted. In addition, the general practitioner did not hospitalize 19 (2%) of 750 patients for whom the decision rule recommended admission. Pre-hospital triage by the general practitioner resulted in a 12% (118 of 977 patients) reduction of the number of patients admitted to the Coronary Care Units.\nCONCLUSIONS: Pre-hospital triage by the general practitioner was facilitated using a standardized questionnaire and pre-hospital electrocardiography, and resulted in a reduction in the number of patients admitted to the Coronary Care Unit, and proved to be safe.","container-title":"European Heart Journal","ISSN":"0195-668X","issue":"1","journalAbbreviation":"Eur. Heart J.","language":"eng","note":"PMID: 8682136","page":"89-95","source":"PubMed","title":"Implementation of a pre-hospital decision rule in general practice. Triage of patients with suspected myocardial infarction","volume":"17","author":[{"family":"Grijseels","given":"E. W."},{"family":"Deckers","given":"J. W."},{"family":"Hoes","given":"A. W."},{"family":"Boersma","given":"E."},{"family":"Hartman","given":"J. A."},{"family":"Does","given":"E.","non-dropping-particle":"van der"},{"family":"Simoons","given":"M. L."}],"issued":{"date-parts":[["1996",1]]}}}],"schema":""} 16,20,30–35. Study CharacteristicsSeven of the eight studies were prospective in nature, with use of CDSS performed ‘on-site’ by either a general practitioner, emergency medical services staff or medical dispatcher ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"dAnnBmum","properties":{"formattedCitation":"\\super 16,30\\uc0\\u8211{}35\\nosupersub{}","plainCitation":"16,30–35","noteIndex":0},"citationItems":[{"id":441,"uris":[""],"uri":[""],"itemData":{"id":441,"type":"article-journal","abstract":"BACKGROUND: To evaluate whether a computer-based decision support system could improve the allocation of patients with acute coronary syndrome (ACS) or a life-threatening condition (LTC). We hypothesised that a system of this kind would improve sensitivity without compromising specificity.\nMETHODS: A total of 2285 consecutive patients who dialed 112 due to chest pain were asked 10 specific questions and a prediction model was constructed based on the answers. We compared the sensitivity of the dispatchers' decisions with that of the model-based decision support model.\nRESULTS: A total of 2048 patients answered all 10 questions. Among the 235 patients with ACS, 194 were allocated the highest prioritisation by dispatchers (sensitivity 82.6%) and 41 patients were given a lower prioritisation (17.4% false negatives). The allocation suggested by the model used the highest prioritisation in 212 of the patients with ACS (sensitivity of 90.2%), while 23 patients were underprioritised (9.8% false negatives). The results were similar when the two systems were compared with regard to LTC and 30-day mortality. This indicates that computer-based decision support could be used either for increasing sensitivity or for saving resources. Three questions proved to be most important in terms of predicting ACS/LTC, [1] the intensity of pain, [2] the localisation of pain and [3] a history of ACS.\nCONCLUSION: Among patients with acute chest pain, computer-based decision support with a model based on a few fundamental questions could improve sensitivity and reduce the number of cases with the highest prioritisation without endangering the patients.","container-title":"International Journal of Cardiology","DOI":"10.1016/j.ijcard.2016.06.281","ISSN":"1874-1754","journalAbbreviation":"Int. J. Cardiol.","language":"eng","note":"PMID: 27393857","page":"734-738","source":"PubMed","title":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support? A cohort of patients with chest pain","title-short":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support?","volume":"220","author":[{"family":"Gellerstedt","given":"Martin"},{"family":"Rawshani","given":"Nina"},{"family":"Herlitz","given":"Johan"},{"family":"B?ng","given":"Angela"},{"family":"Gelang","given":"Carita"},{"family":"Andersson","given":"Jan-Otto"},{"family":"Larsson","given":"Anna"},{"family":"Rawshani","given":"Araz"}],"issued":{"date-parts":[["2016",10,1]]}}},{"id":220,"uris":[""],"uri":[""],"itemData":{"id":220,"type":"article-journal","abstract":"OBJECTIVE: ST-elevation myocardial infarction (STEMI) identification by emergency medicine services (EMS) leading to pre-hospital catheterization laboratory (CL) activation shortens ischemic time and improves outcomes. We examined the incremental value of addition of a screening clinical tool (CT), containing clinical information and a Zoll electrocardiogram (ECG)-resident STEMI identification program (ZI) to ZI alone.\nMETHODS: All EMS-performed and ZI-analyzed ECGs transmitted to a percutaneous coronary intervention hospital from October 2009 to January 2011 were reviewed for diagnostic accuracy. ZI performance was also compared to ECG interpretations by 2 experienced readers The CT was then retrospectively applied to determine the incremental benefit above the ZI alone.\nRESULTS: ST-elevation myocardial infarction was confirmed in 23 (7.5%) of 305 patients. ZI was positive in 37 (12.1%): sensitivity: 95.6% and specificity: 94.6%, positive predictive value (PPV), 59.5%, negative predictive value (NPV), 99.6%, and accuracy of 93.8%. Moderate agreement was observed among the readers and ZI. CT criteria for CL activation were met in 24 (7.8%): 20 (83.3%) were confirmed STEMIs: sensitivity: 86.9%, specificity: 98.5%, a PPV: 83.3%, and NPV: 98.6%, accuracy of 97.7%. CT + ZI increased PPV (P<0.05) and specificity (P<0.003) by reducing false positive STEMI identifications from 15 (4.9%) to 4 (1.3%).\nCONCLUSIONS: In an urban cohort of all EMS transmitted ECGs, ZI has high sensitivity and specificity for STEMI identification. Whereas the PPV was low, reflecting both low STEMI prevalence and presence of STEMI-mimics, the NPV was very high. These findings suggest that a simplified CT combined with computer STEMI interpretation can identify patients for pre-hospital CL activation. Confirmation of these results could improve the design of STEMI care systems.","container-title":"The American Journal of Emergency Medicine","DOI":"10.1016/j.ajem.2013.04.013","ISSN":"1532-8171","issue":"7","journalAbbreviation":"Am J Emerg Med","language":"eng","note":"PMID: 23706572","page":"1098-1102","source":"PubMed","title":"An algorithm for identification of ST-elevation myocardial infarction patients by emergency medicine services","volume":"31","author":[{"family":"Wilson","given":"Ryan E."},{"family":"Kado","given":"Herman S."},{"family":"Percy","given":"Robert F."},{"family":"Butterfield","given":"Ryan C."},{"family":"Sabato","given":"Joseph"},{"family":"Strom","given":"Joel A."},{"family":"Box","given":"Lyndon C."}],"issued":{"date-parts":[["2013",7]]}}},{"id":439,"uris":[""],"uri":[""],"itemData":{"id":439,"type":"article-journal","abstract":"BACKGROUND: The first study of the FamouS Triage project investigates the feasibility of ruling out a myocardial infarction in pre-hospital chest pain patients without electrocardiographic ST-segment elevation by using the modified HEART score at the patient's home, incorporating only a single highly sensitive troponin T measurement.\nMETHODS: A venous blood sample was drawn in the ambulance from 1127 consecutive chest pain patients for measurement of the pre-hospital highly sensitive troponin T levels, in order to establish a pre-hospital HEART score (i.e. the modified HEART score) and evaluate the possibility of triage at the patient's home. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) i.e. acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or death within 30 days after initial presentation.\nRESULTS: Two hundred and six patients (18%) developed a MACE during 30 days of follow-up. Thirty-six per cent of the patients ( n=403) had a low modified HEART score (0-3 points) and none of them developed a MACE during follow-up. Forty-four per cent of the patients ( n=494) had an intermediate modified HEART score (4-6 points) and 18% of them developed a MACE. Twenty per cent of the patients ( n=230) had a high modified HEART score (7-10 points) of which 52% developed a MACE during follow-up.\nCONCLUSION: It seems feasible to rule out a myocardial infarction at home in chest pain patients without ST-segment elevation by using the modified HEART score.\nTRIAL ID: NTR4205. Dutch Trial Register [ ]: trial number 4205.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872616687116","ISSN":"2048-8734","issue":"2","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 28084079","page":"102-110","source":"PubMed","title":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score","title-short":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage)","volume":"7","author":[{"family":"Ishak","given":"Maycel"},{"family":"Ali","given":"Danish"},{"family":"Fokkert","given":"Marion J."},{"family":"Slingerland","given":"Robbert J."},{"family":"Tolsma","given":"Rudolf T."},{"family":"Badings","given":"Erik"},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Eenennaam","given":"Fred","non-dropping-particle":"van"},{"family":"Mosterd","given":"Arend"},{"family":"Ten Berg","given":"Jurri?n M."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"}],"issued":{"date-parts":[["2018",3]]}}},{"id":437,"uris":[""],"uri":[""],"itemData":{"id":437,"type":"article-journal","abstract":"BACKGROUND: The purposes of this study were to create a new flow-chart of prehospital electrocardiography (ECG)-transmission, evaluate its predictive ability for ST-elevation myocardial infarction (STEMI) and shorten door-to-balloon time (DTBT).\nMETHOD AND RESULTS: The new transmission flow-chart was created using symptoms from previous medical records of STEMI patients. A total of 4090 consecutive patients transferred emergently to our hospital were divided into two groups: those in ambulances with an ECG-transmission device with the new flow-chart (ECGT-FC) and those transferred without an ECG-transmission device (non-ECGT) groups. A STEMI group comprising walk-in patients during the same period was used as a control group. The predictive ability of STEMI and the effectiveness of shortening the DTBT by the new flow-chart of ECG-transmission was evaluated. In the ECGT-FC group, the prevalence of STEMI in the ECG-transmission by the new flow-chart were significantly higher than in the non-ECG-transmission patients (6.71% vs. 0.19%; p<0.001). The sensitivity and specificity of the new ECG-transmission flow-chart were 83.3% and 88.1%, respectively. The median DTBT was significantly shortened (p=0.045) and the prevalence of DTBT<90min was significantly higher in the ECGT-FC group (p=0.018) than the other groups.\nCONCLUSION: The sensitivity and specificity of the new flow-chart for ECG-transmission were high. The new flow-chart combined with an ECG-transmission device could detect STEMI efficiently and shorten DTBT.","container-title":"Journal of Cardiology","DOI":"10.1016/j.jjcc.2018.03.011","ISSN":"1876-4738","issue":"4","journalAbbreviation":"J Cardiol","language":"eng","note":"PMID: 29804908","page":"335-342","source":"PubMed","title":"Predictive ability and efficacy for shortening door-to-balloon time of a new prehospital electrocardiogram-transmission flow chart in patients with ST-elevation myocardial infarction - Results of the CASSIOPEIA study","volume":"72","author":[{"family":"Sakai","given":"Toshiaki"},{"family":"Nishiyama","given":"Osamu"},{"family":"Onodera","given":"Masayuki"},{"family":"Matsuda","given":"Shigekatsu"},{"family":"Wakisawa","given":"Shinobu"},{"family":"Nakamura","given":"Motoyuki"},{"family":"Morino","given":"Yoshihiro"},{"family":"Itoh","given":"Tomonori"},{"literal":"CASSIOPEIA study group"}],"issued":{"date-parts":[["2018",10]]}}},{"id":447,"uris":[""],"uri":[""],"itemData":{"id":447,"type":"article-journal","abstract":"BACKGROUND: Diagnosing acute coronary syndrome (ACS) in a primary care setting poses a diagnostic dilemma for physicians.\nOBJECTIVE: We directly compared the diagnostic accuracy of a clinical decision rule (CDR) based on history taking and physical examination in suspected ACS with the risk estimates of the attending GP.\nMETHODS: In a prospective multicenter study, patients suspected of ACS were included by the GP. GPs were asked to estimate the probability (0%-100%) of the presence of ACS. GPs collected patient data, but they were not aware of the CDR and did not score the patient accordingly.\nRESULTS: Two hundred and ninety-eight patients were included (52% female, mean age 66 years, 22% ACS). The area under the receiver operating characteristic (ROC) curve (AUC) was 0.75 [95% confidence interval (CI) 0.68-0.82] for the GP risk estimate and 0.66 (95% CI 0.58-0.73) for the CDR. There was an agreement between the risk estimation of the GP and a CDR in 51% and the prevalence of ACS in predefined low-, intermediate- and high-risk groups was similar for the GP and CDR estimates. In the low-risk group, according to the GP, four patients (8.2%) suffered an ACS. These four patients were all identified by the decision rule as high risk.\nCONCLUSIONS: The GP classified patients as ACS or no ACS more adequately than the CDR, judged by the AUC. However, the use of a CDR in patients that are considered at low risk for ACS by the GP could reduce the amount of missed myocardial infarctions.","container-title":"Family Practice","DOI":"10.1093/fampra/cmq116","ISSN":"1460-2229","issue":"3","journalAbbreviation":"Fam Pract","language":"eng","note":"PMID: 21239470","page":"323-328","source":"PubMed","title":"Diagnosing acute coronary syndrome in primary care: comparison of the physicians' risk estimation and a clinical decision rule","title-short":"Diagnosing acute coronary syndrome in primary care","volume":"28","author":[{"family":"Bruins Slot","given":"M. H. E."},{"family":"Rutten","given":"F. H."},{"family":"Heijden","given":"G. J. M. G.","non-dropping-particle":"van der"},{"family":"Geersing","given":"G. J."},{"family":"Glatz","given":"J. F. C."},{"family":"Hoes","given":"A. W."}],"issued":{"date-parts":[["2011",6]]}}},{"id":435,"uris":[""],"uri":[""],"itemData":{"id":435,"type":"article-journal","abstract":"BACKGROUND:: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE).\nMETHODS:: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ? 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death.\nRESULTS:: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%).\nCONCLUSIONS:: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872618813846","ISSN":"2048-8734","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 30468395","page":"2048872618813846","source":"PubMed","title":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study","title-short":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome","author":[{"family":"Dongen","given":"Dominique N.","non-dropping-particle":"van"},{"family":"Tolsma","given":"Rudolf T."},{"family":"Fokkert","given":"Marion J."},{"family":"Badings","given":"Erik A."},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Slingerland","given":"Robbert J."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"},{"family":"Ottervanger","given":"Jan Paul"}],"issued":{"date-parts":[["2018",11,23]]}}},{"id":478,"uris":[""],"uri":[""],"itemData":{"id":478,"type":"article-journal","abstract":"OBJECTIVE: To improve pre-hospital triage of patients with suspected acute cardiac disease.\nDESIGN: Prospective study. SUBJECTS. Patients with symptoms suggestive of acute cardiac pathology, who were seen by a general practitioner, for whom acute admission into hospital was requested, and in whom a pre-hospital electrocardiogram was recorded by the ambulance service.\nMETHODS: The study consisted of two phases. In the first phase, a decision rule was developed based on clinical characteristics and electrocardiographic findings in 1005 patients with suspected acute cardiac pathology. In the second phase, the decision rule was prospectively validated. Symptoms were recorded by a standardized questionnaire by the general practitioner and a computerized electrocardiogram was made by the ambulance nurses at the patient's home. Three electrocardiographic outcomes were available: 'normal electrocardiogram', 'possible myocardial infarction' or 'extensive myocardial infarction'. By use of the predictive model, the general practitioner could decide if hospitalization was necessary or not.\nMAIN OUTCOME MEASUREMENTS: Identification of patients at low (stable angina, atypical chest pain, other pathology) and high (myocardial infarction, unstable angina) probability of acute cardiac pathology.\nRESULTS: Among 977 patients with a complete pre-hospital evaluation in the validation phase of the study, the decision rule recommended 'no hospitalization' in 227 patients (23%). The general practitioner followed this advice in 44% of these patients. Although seven of them developed a non-Q wave myocardial infarction, no complications occurred in patients not admitted. In addition, the general practitioner did not hospitalize 19 (2%) of 750 patients for whom the decision rule recommended admission. Pre-hospital triage by the general practitioner resulted in a 12% (118 of 977 patients) reduction of the number of patients admitted to the Coronary Care Units.\nCONCLUSIONS: Pre-hospital triage by the general practitioner was facilitated using a standardized questionnaire and pre-hospital electrocardiography, and resulted in a reduction in the number of patients admitted to the Coronary Care Unit, and proved to be safe.","container-title":"European Heart Journal","ISSN":"0195-668X","issue":"1","journalAbbreviation":"Eur. Heart J.","language":"eng","note":"PMID: 8682136","page":"89-95","source":"PubMed","title":"Implementation of a pre-hospital decision rule in general practice. Triage of patients with suspected myocardial infarction","volume":"17","author":[{"family":"Grijseels","given":"E. W."},{"family":"Deckers","given":"J. W."},{"family":"Hoes","given":"A. W."},{"family":"Boersma","given":"E."},{"family":"Hartman","given":"J. A."},{"family":"Does","given":"E.","non-dropping-particle":"van der"},{"family":"Simoons","given":"M. L."}],"issued":{"date-parts":[["1996",1]]}}}],"schema":""} 16,30–35. Two studies were retrospective analyses of patients and included either computer-aided ECG interpretation and decision-making ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"O3ifgOsu","properties":{"formattedCitation":"\\super 20,34\\nosupersub{}","plainCitation":"20,34","noteIndex":0},"citationItems":[{"id":445,"uris":[""],"uri":[""],"itemData":{"id":445,"type":"article-journal","abstract":"BACKGROUND: Identifying ST-segment elevation myocardial infarctions (STEMIs) in the field can decrease door-to-balloon times. Paramedics may use a computer algorithm to help them interpret prehospital electrocariograms (ECGs). It is unknown how accurately the computer can identify STEMIs.\nOBJECTIVES: To Determine the sensitivity and specificity of prehospital ECGs in identifying patients with STEMI.\nMETHODS: Retrospective cross-sectional study of 200 prehospital ECGs acquired using Lifepak 12 monitors and transmitted by one of more than 20 emergency medical services (EMS) agencies to the emergency department (ED) of a Summa Akron City Hospital, a level 1 trauma center between January 1, 2007, and February 18, 2010. The ED sees more than 73,000 adult patients and treats 120 STEMIs annually. The laboratory performs 3,400 catheterizations annually. The first 100 patients with a diagnosis of STEMI and cardiac catheterization laboratory activation from the ED were analyzed. For comparison, a control group of 100 other ECGs from patients without a STEMI were randomly selected from our Medtronic database using a random-number generator. For patients with STEMI, an accurate computer interpretation was \"acute MI suspected.\" Other interpretations were counted as misses. Specificity and sensitivity were calculated with confidence intervals (CIs). The sample size was determined a priori for a 95% CI of ±10%.\nRESULTS: Zero control patients were incorrectly labeled \"acute MI suspected.\" The specificity was 100% (100/100; 95% CI 0.96-1.0), whereas the sensitivity was 58% (58/100; 95% CI 0.48-0.67). This would have resulted in 42 missed cardiac catheterization laboratory activations, but zero inappropriate activations. The most common incorrect interpretation of STEMI ECGs by the computer was \"data quality prohibits interpretation,\" followed by \"abnormal ECG unconfirmed.\"\nCONCLUSIONS: Prehospital computer interpretation is not sensitive for STEMI identification and should not be used as a single method for prehospital activation of the cardiac catheterizing laboratory. Because of its high specificity, it may serve as an adjunct to interpretation.","container-title":"Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors","DOI":"10.3109/10903127.2012.722176","ISSN":"1545-0066","issue":"2","journalAbbreviation":"Prehosp Emerg Care","language":"eng","note":"PMID: 23066910","page":"211-216","source":"PubMed","title":"Prehospital electrocardiographic computer identification of ST-segment elevation myocardial infarction","volume":"17","author":[{"family":"Bhalla","given":"Mary Colleen"},{"family":"Mencl","given":"Francis"},{"family":"Gist","given":"Mikki Amber"},{"family":"Wilber","given":"Scott"},{"family":"Zalewski","given":"Jon"}],"issued":{"date-parts":[["2013",6]]}}},{"id":220,"uris":[""],"uri":[""],"itemData":{"id":220,"type":"article-journal","abstract":"OBJECTIVE: ST-elevation myocardial infarction (STEMI) identification by emergency medicine services (EMS) leading to pre-hospital catheterization laboratory (CL) activation shortens ischemic time and improves outcomes. We examined the incremental value of addition of a screening clinical tool (CT), containing clinical information and a Zoll electrocardiogram (ECG)-resident STEMI identification program (ZI) to ZI alone.\nMETHODS: All EMS-performed and ZI-analyzed ECGs transmitted to a percutaneous coronary intervention hospital from October 2009 to January 2011 were reviewed for diagnostic accuracy. ZI performance was also compared to ECG interpretations by 2 experienced readers The CT was then retrospectively applied to determine the incremental benefit above the ZI alone.\nRESULTS: ST-elevation myocardial infarction was confirmed in 23 (7.5%) of 305 patients. ZI was positive in 37 (12.1%): sensitivity: 95.6% and specificity: 94.6%, positive predictive value (PPV), 59.5%, negative predictive value (NPV), 99.6%, and accuracy of 93.8%. Moderate agreement was observed among the readers and ZI. CT criteria for CL activation were met in 24 (7.8%): 20 (83.3%) were confirmed STEMIs: sensitivity: 86.9%, specificity: 98.5%, a PPV: 83.3%, and NPV: 98.6%, accuracy of 97.7%. CT + ZI increased PPV (P<0.05) and specificity (P<0.003) by reducing false positive STEMI identifications from 15 (4.9%) to 4 (1.3%).\nCONCLUSIONS: In an urban cohort of all EMS transmitted ECGs, ZI has high sensitivity and specificity for STEMI identification. Whereas the PPV was low, reflecting both low STEMI prevalence and presence of STEMI-mimics, the NPV was very high. These findings suggest that a simplified CT combined with computer STEMI interpretation can identify patients for pre-hospital CL activation. Confirmation of these results could improve the design of STEMI care systems.","container-title":"The American Journal of Emergency Medicine","DOI":"10.1016/j.ajem.2013.04.013","ISSN":"1532-8171","issue":"7","journalAbbreviation":"Am J Emerg Med","language":"eng","note":"PMID: 23706572","page":"1098-1102","source":"PubMed","title":"An algorithm for identification of ST-elevation myocardial infarction patients by emergency medicine services","volume":"31","author":[{"family":"Wilson","given":"Ryan E."},{"family":"Kado","given":"Herman S."},{"family":"Percy","given":"Robert F."},{"family":"Butterfield","given":"Ryan C."},{"family":"Sabato","given":"Joseph"},{"family":"Strom","given":"Joel A."},{"family":"Box","given":"Lyndon C."}],"issued":{"date-parts":[["2013",7]]}}}],"schema":""} 20,34. Table 1 displays the demographic characteristics of the patients in the eight studies. A total of 354,259 patients were in the studies combined; however, one study contributed 347,989 patients making up 98% of the total population. The average number of patients excluded was 69, the majority being from one study which only had data on 15% of patients ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"wLlLdAda","properties":{"formattedCitation":"\\super 30\\nosupersub{}","plainCitation":"30","noteIndex":0},"citationItems":[{"id":441,"uris":[""],"uri":[""],"itemData":{"id":441,"type":"article-journal","abstract":"BACKGROUND: To evaluate whether a computer-based decision support system could improve the allocation of patients with acute coronary syndrome (ACS) or a life-threatening condition (LTC). We hypothesised that a system of this kind would improve sensitivity without compromising specificity.\nMETHODS: A total of 2285 consecutive patients who dialed 112 due to chest pain were asked 10 specific questions and a prediction model was constructed based on the answers. We compared the sensitivity of the dispatchers' decisions with that of the model-based decision support model.\nRESULTS: A total of 2048 patients answered all 10 questions. Among the 235 patients with ACS, 194 were allocated the highest prioritisation by dispatchers (sensitivity 82.6%) and 41 patients were given a lower prioritisation (17.4% false negatives). The allocation suggested by the model used the highest prioritisation in 212 of the patients with ACS (sensitivity of 90.2%), while 23 patients were underprioritised (9.8% false negatives). The results were similar when the two systems were compared with regard to LTC and 30-day mortality. This indicates that computer-based decision support could be used either for increasing sensitivity or for saving resources. Three questions proved to be most important in terms of predicting ACS/LTC, [1] the intensity of pain, [2] the localisation of pain and [3] a history of ACS.\nCONCLUSION: Among patients with acute chest pain, computer-based decision support with a model based on a few fundamental questions could improve sensitivity and reduce the number of cases with the highest prioritisation without endangering the patients.","container-title":"International Journal of Cardiology","DOI":"10.1016/j.ijcard.2016.06.281","ISSN":"1874-1754","journalAbbreviation":"Int. J. Cardiol.","language":"eng","note":"PMID: 27393857","page":"734-738","source":"PubMed","title":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support? A cohort of patients with chest pain","title-short":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support?","volume":"220","author":[{"family":"Gellerstedt","given":"Martin"},{"family":"Rawshani","given":"Nina"},{"family":"Herlitz","given":"Johan"},{"family":"B?ng","given":"Angela"},{"family":"Gelang","given":"Carita"},{"family":"Andersson","given":"Jan-Otto"},{"family":"Larsson","given":"Anna"},{"family":"Rawshani","given":"Araz"}],"issued":{"date-parts":[["2016",10,1]]}}}],"schema":""} 30. Mean age was 65 years and 54% of participants were male. Half of the studies were conducted in the Netherlands, with a further two in the United States and the remainder in Sweden and Japan. Five studies involved emergency medical services, two involved general practitioners and one involved a medical call dispatch team. HeterogeneityThere was a large degree of heterogeneity in the eight studies. The first study was published in 1996, and the last 22 years later in 2018 ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"QFOoy4eQ","properties":{"formattedCitation":"\\super 16,33\\nosupersub{}","plainCitation":"16,33","noteIndex":0},"citationItems":[{"id":435,"uris":[""],"uri":[""],"itemData":{"id":435,"type":"article-journal","abstract":"BACKGROUND:: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE).\nMETHODS:: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ? 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death.\nRESULTS:: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%).\nCONCLUSIONS:: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872618813846","ISSN":"2048-8734","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 30468395","page":"2048872618813846","source":"PubMed","title":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study","title-short":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome","author":[{"family":"Dongen","given":"Dominique N.","non-dropping-particle":"van"},{"family":"Tolsma","given":"Rudolf T."},{"family":"Fokkert","given":"Marion J."},{"family":"Badings","given":"Erik A."},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Slingerland","given":"Robbert J."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"},{"family":"Ottervanger","given":"Jan Paul"}],"issued":{"date-parts":[["2018",11,23]]}}},{"id":478,"uris":[""],"uri":[""],"itemData":{"id":478,"type":"article-journal","abstract":"OBJECTIVE: To improve pre-hospital triage of patients with suspected acute cardiac disease.\nDESIGN: Prospective study. SUBJECTS. Patients with symptoms suggestive of acute cardiac pathology, who were seen by a general practitioner, for whom acute admission into hospital was requested, and in whom a pre-hospital electrocardiogram was recorded by the ambulance service.\nMETHODS: The study consisted of two phases. In the first phase, a decision rule was developed based on clinical characteristics and electrocardiographic findings in 1005 patients with suspected acute cardiac pathology. In the second phase, the decision rule was prospectively validated. Symptoms were recorded by a standardized questionnaire by the general practitioner and a computerized electrocardiogram was made by the ambulance nurses at the patient's home. Three electrocardiographic outcomes were available: 'normal electrocardiogram', 'possible myocardial infarction' or 'extensive myocardial infarction'. By use of the predictive model, the general practitioner could decide if hospitalization was necessary or not.\nMAIN OUTCOME MEASUREMENTS: Identification of patients at low (stable angina, atypical chest pain, other pathology) and high (myocardial infarction, unstable angina) probability of acute cardiac pathology.\nRESULTS: Among 977 patients with a complete pre-hospital evaluation in the validation phase of the study, the decision rule recommended 'no hospitalization' in 227 patients (23%). The general practitioner followed this advice in 44% of these patients. Although seven of them developed a non-Q wave myocardial infarction, no complications occurred in patients not admitted. In addition, the general practitioner did not hospitalize 19 (2%) of 750 patients for whom the decision rule recommended admission. Pre-hospital triage by the general practitioner resulted in a 12% (118 of 977 patients) reduction of the number of patients admitted to the Coronary Care Units.\nCONCLUSIONS: Pre-hospital triage by the general practitioner was facilitated using a standardized questionnaire and pre-hospital electrocardiography, and resulted in a reduction in the number of patients admitted to the Coronary Care Unit, and proved to be safe.","container-title":"European Heart Journal","ISSN":"0195-668X","issue":"1","journalAbbreviation":"Eur. Heart J.","language":"eng","note":"PMID: 8682136","page":"89-95","source":"PubMed","title":"Implementation of a pre-hospital decision rule in general practice. Triage of patients with suspected myocardial infarction","volume":"17","author":[{"family":"Grijseels","given":"E. W."},{"family":"Deckers","given":"J. W."},{"family":"Hoes","given":"A. W."},{"family":"Boersma","given":"E."},{"family":"Hartman","given":"J. A."},{"family":"Does","given":"E.","non-dropping-particle":"van der"},{"family":"Simoons","given":"M. L."}],"issued":{"date-parts":[["1996",1]]}}}],"schema":""} 16,33. As noted above, seven of the studies were prospective and one was retrospective in design. The composition of the CDSS components differed, with seven studies involving patient history ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"sCpvb6QS","properties":{"formattedCitation":"\\super 16,30\\uc0\\u8211{}35\\nosupersub{}","plainCitation":"16,30–35","noteIndex":0},"citationItems":[{"id":441,"uris":[""],"uri":[""],"itemData":{"id":441,"type":"article-journal","abstract":"BACKGROUND: To evaluate whether a computer-based decision support system could improve the allocation of patients with acute coronary syndrome (ACS) or a life-threatening condition (LTC). We hypothesised that a system of this kind would improve sensitivity without compromising specificity.\nMETHODS: A total of 2285 consecutive patients who dialed 112 due to chest pain were asked 10 specific questions and a prediction model was constructed based on the answers. We compared the sensitivity of the dispatchers' decisions with that of the model-based decision support model.\nRESULTS: A total of 2048 patients answered all 10 questions. Among the 235 patients with ACS, 194 were allocated the highest prioritisation by dispatchers (sensitivity 82.6%) and 41 patients were given a lower prioritisation (17.4% false negatives). The allocation suggested by the model used the highest prioritisation in 212 of the patients with ACS (sensitivity of 90.2%), while 23 patients were underprioritised (9.8% false negatives). The results were similar when the two systems were compared with regard to LTC and 30-day mortality. This indicates that computer-based decision support could be used either for increasing sensitivity or for saving resources. Three questions proved to be most important in terms of predicting ACS/LTC, [1] the intensity of pain, [2] the localisation of pain and [3] a history of ACS.\nCONCLUSION: Among patients with acute chest pain, computer-based decision support with a model based on a few fundamental questions could improve sensitivity and reduce the number of cases with the highest prioritisation without endangering the patients.","container-title":"International Journal of Cardiology","DOI":"10.1016/j.ijcard.2016.06.281","ISSN":"1874-1754","journalAbbreviation":"Int. J. Cardiol.","language":"eng","note":"PMID: 27393857","page":"734-738","source":"PubMed","title":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support? A cohort of patients with chest pain","title-short":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support?","volume":"220","author":[{"family":"Gellerstedt","given":"Martin"},{"family":"Rawshani","given":"Nina"},{"family":"Herlitz","given":"Johan"},{"family":"B?ng","given":"Angela"},{"family":"Gelang","given":"Carita"},{"family":"Andersson","given":"Jan-Otto"},{"family":"Larsson","given":"Anna"},{"family":"Rawshani","given":"Araz"}],"issued":{"date-parts":[["2016",10,1]]}}},{"id":220,"uris":[""],"uri":[""],"itemData":{"id":220,"type":"article-journal","abstract":"OBJECTIVE: ST-elevation myocardial infarction (STEMI) identification by emergency medicine services (EMS) leading to pre-hospital catheterization laboratory (CL) activation shortens ischemic time and improves outcomes. We examined the incremental value of addition of a screening clinical tool (CT), containing clinical information and a Zoll electrocardiogram (ECG)-resident STEMI identification program (ZI) to ZI alone.\nMETHODS: All EMS-performed and ZI-analyzed ECGs transmitted to a percutaneous coronary intervention hospital from October 2009 to January 2011 were reviewed for diagnostic accuracy. ZI performance was also compared to ECG interpretations by 2 experienced readers The CT was then retrospectively applied to determine the incremental benefit above the ZI alone.\nRESULTS: ST-elevation myocardial infarction was confirmed in 23 (7.5%) of 305 patients. ZI was positive in 37 (12.1%): sensitivity: 95.6% and specificity: 94.6%, positive predictive value (PPV), 59.5%, negative predictive value (NPV), 99.6%, and accuracy of 93.8%. Moderate agreement was observed among the readers and ZI. CT criteria for CL activation were met in 24 (7.8%): 20 (83.3%) were confirmed STEMIs: sensitivity: 86.9%, specificity: 98.5%, a PPV: 83.3%, and NPV: 98.6%, accuracy of 97.7%. CT + ZI increased PPV (P<0.05) and specificity (P<0.003) by reducing false positive STEMI identifications from 15 (4.9%) to 4 (1.3%).\nCONCLUSIONS: In an urban cohort of all EMS transmitted ECGs, ZI has high sensitivity and specificity for STEMI identification. Whereas the PPV was low, reflecting both low STEMI prevalence and presence of STEMI-mimics, the NPV was very high. These findings suggest that a simplified CT combined with computer STEMI interpretation can identify patients for pre-hospital CL activation. Confirmation of these results could improve the design of STEMI care systems.","container-title":"The American Journal of Emergency Medicine","DOI":"10.1016/j.ajem.2013.04.013","ISSN":"1532-8171","issue":"7","journalAbbreviation":"Am J Emerg Med","language":"eng","note":"PMID: 23706572","page":"1098-1102","source":"PubMed","title":"An algorithm for identification of ST-elevation myocardial infarction patients by emergency medicine services","volume":"31","author":[{"family":"Wilson","given":"Ryan E."},{"family":"Kado","given":"Herman S."},{"family":"Percy","given":"Robert F."},{"family":"Butterfield","given":"Ryan C."},{"family":"Sabato","given":"Joseph"},{"family":"Strom","given":"Joel A."},{"family":"Box","given":"Lyndon C."}],"issued":{"date-parts":[["2013",7]]}}},{"id":439,"uris":[""],"uri":[""],"itemData":{"id":439,"type":"article-journal","abstract":"BACKGROUND: The first study of the FamouS Triage project investigates the feasibility of ruling out a myocardial infarction in pre-hospital chest pain patients without electrocardiographic ST-segment elevation by using the modified HEART score at the patient's home, incorporating only a single highly sensitive troponin T measurement.\nMETHODS: A venous blood sample was drawn in the ambulance from 1127 consecutive chest pain patients for measurement of the pre-hospital highly sensitive troponin T levels, in order to establish a pre-hospital HEART score (i.e. the modified HEART score) and evaluate the possibility of triage at the patient's home. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) i.e. acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or death within 30 days after initial presentation.\nRESULTS: Two hundred and six patients (18%) developed a MACE during 30 days of follow-up. Thirty-six per cent of the patients ( n=403) had a low modified HEART score (0-3 points) and none of them developed a MACE during follow-up. Forty-four per cent of the patients ( n=494) had an intermediate modified HEART score (4-6 points) and 18% of them developed a MACE. Twenty per cent of the patients ( n=230) had a high modified HEART score (7-10 points) of which 52% developed a MACE during follow-up.\nCONCLUSION: It seems feasible to rule out a myocardial infarction at home in chest pain patients without ST-segment elevation by using the modified HEART score.\nTRIAL ID: NTR4205. Dutch Trial Register [ ]: trial number 4205.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872616687116","ISSN":"2048-8734","issue":"2","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 28084079","page":"102-110","source":"PubMed","title":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score","title-short":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage)","volume":"7","author":[{"family":"Ishak","given":"Maycel"},{"family":"Ali","given":"Danish"},{"family":"Fokkert","given":"Marion J."},{"family":"Slingerland","given":"Robbert J."},{"family":"Tolsma","given":"Rudolf T."},{"family":"Badings","given":"Erik"},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Eenennaam","given":"Fred","non-dropping-particle":"van"},{"family":"Mosterd","given":"Arend"},{"family":"Ten Berg","given":"Jurri?n M."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"}],"issued":{"date-parts":[["2018",3]]}}},{"id":437,"uris":[""],"uri":[""],"itemData":{"id":437,"type":"article-journal","abstract":"BACKGROUND: The purposes of this study were to create a new flow-chart of prehospital electrocardiography (ECG)-transmission, evaluate its predictive ability for ST-elevation myocardial infarction (STEMI) and shorten door-to-balloon time (DTBT).\nMETHOD AND RESULTS: The new transmission flow-chart was created using symptoms from previous medical records of STEMI patients. A total of 4090 consecutive patients transferred emergently to our hospital were divided into two groups: those in ambulances with an ECG-transmission device with the new flow-chart (ECGT-FC) and those transferred without an ECG-transmission device (non-ECGT) groups. A STEMI group comprising walk-in patients during the same period was used as a control group. The predictive ability of STEMI and the effectiveness of shortening the DTBT by the new flow-chart of ECG-transmission was evaluated. In the ECGT-FC group, the prevalence of STEMI in the ECG-transmission by the new flow-chart were significantly higher than in the non-ECG-transmission patients (6.71% vs. 0.19%; p<0.001). The sensitivity and specificity of the new ECG-transmission flow-chart were 83.3% and 88.1%, respectively. The median DTBT was significantly shortened (p=0.045) and the prevalence of DTBT<90min was significantly higher in the ECGT-FC group (p=0.018) than the other groups.\nCONCLUSION: The sensitivity and specificity of the new flow-chart for ECG-transmission were high. The new flow-chart combined with an ECG-transmission device could detect STEMI efficiently and shorten DTBT.","container-title":"Journal of Cardiology","DOI":"10.1016/j.jjcc.2018.03.011","ISSN":"1876-4738","issue":"4","journalAbbreviation":"J Cardiol","language":"eng","note":"PMID: 29804908","page":"335-342","source":"PubMed","title":"Predictive ability and efficacy for shortening door-to-balloon time of a new prehospital electrocardiogram-transmission flow chart in patients with ST-elevation myocardial infarction - Results of the CASSIOPEIA study","volume":"72","author":[{"family":"Sakai","given":"Toshiaki"},{"family":"Nishiyama","given":"Osamu"},{"family":"Onodera","given":"Masayuki"},{"family":"Matsuda","given":"Shigekatsu"},{"family":"Wakisawa","given":"Shinobu"},{"family":"Nakamura","given":"Motoyuki"},{"family":"Morino","given":"Yoshihiro"},{"family":"Itoh","given":"Tomonori"},{"literal":"CASSIOPEIA study group"}],"issued":{"date-parts":[["2018",10]]}}},{"id":447,"uris":[""],"uri":[""],"itemData":{"id":447,"type":"article-journal","abstract":"BACKGROUND: Diagnosing acute coronary syndrome (ACS) in a primary care setting poses a diagnostic dilemma for physicians.\nOBJECTIVE: We directly compared the diagnostic accuracy of a clinical decision rule (CDR) based on history taking and physical examination in suspected ACS with the risk estimates of the attending GP.\nMETHODS: In a prospective multicenter study, patients suspected of ACS were included by the GP. GPs were asked to estimate the probability (0%-100%) of the presence of ACS. GPs collected patient data, but they were not aware of the CDR and did not score the patient accordingly.\nRESULTS: Two hundred and ninety-eight patients were included (52% female, mean age 66 years, 22% ACS). The area under the receiver operating characteristic (ROC) curve (AUC) was 0.75 [95% confidence interval (CI) 0.68-0.82] for the GP risk estimate and 0.66 (95% CI 0.58-0.73) for the CDR. There was an agreement between the risk estimation of the GP and a CDR in 51% and the prevalence of ACS in predefined low-, intermediate- and high-risk groups was similar for the GP and CDR estimates. In the low-risk group, according to the GP, four patients (8.2%) suffered an ACS. These four patients were all identified by the decision rule as high risk.\nCONCLUSIONS: The GP classified patients as ACS or no ACS more adequately than the CDR, judged by the AUC. However, the use of a CDR in patients that are considered at low risk for ACS by the GP could reduce the amount of missed myocardial infarctions.","container-title":"Family Practice","DOI":"10.1093/fampra/cmq116","ISSN":"1460-2229","issue":"3","journalAbbreviation":"Fam Pract","language":"eng","note":"PMID: 21239470","page":"323-328","source":"PubMed","title":"Diagnosing acute coronary syndrome in primary care: comparison of the physicians' risk estimation and a clinical decision rule","title-short":"Diagnosing acute coronary syndrome in primary care","volume":"28","author":[{"family":"Bruins Slot","given":"M. H. E."},{"family":"Rutten","given":"F. H."},{"family":"Heijden","given":"G. J. M. G.","non-dropping-particle":"van der"},{"family":"Geersing","given":"G. J."},{"family":"Glatz","given":"J. F. C."},{"family":"Hoes","given":"A. W."}],"issued":{"date-parts":[["2011",6]]}}},{"id":435,"uris":[""],"uri":[""],"itemData":{"id":435,"type":"article-journal","abstract":"BACKGROUND:: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE).\nMETHODS:: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ? 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death.\nRESULTS:: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%).\nCONCLUSIONS:: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872618813846","ISSN":"2048-8734","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 30468395","page":"2048872618813846","source":"PubMed","title":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study","title-short":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome","author":[{"family":"Dongen","given":"Dominique N.","non-dropping-particle":"van"},{"family":"Tolsma","given":"Rudolf T."},{"family":"Fokkert","given":"Marion J."},{"family":"Badings","given":"Erik A."},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Slingerland","given":"Robbert J."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"},{"family":"Ottervanger","given":"Jan Paul"}],"issued":{"date-parts":[["2018",11,23]]}}},{"id":478,"uris":[""],"uri":[""],"itemData":{"id":478,"type":"article-journal","abstract":"OBJECTIVE: To improve pre-hospital triage of patients with suspected acute cardiac disease.\nDESIGN: Prospective study. SUBJECTS. Patients with symptoms suggestive of acute cardiac pathology, who were seen by a general practitioner, for whom acute admission into hospital was requested, and in whom a pre-hospital electrocardiogram was recorded by the ambulance service.\nMETHODS: The study consisted of two phases. In the first phase, a decision rule was developed based on clinical characteristics and electrocardiographic findings in 1005 patients with suspected acute cardiac pathology. In the second phase, the decision rule was prospectively validated. Symptoms were recorded by a standardized questionnaire by the general practitioner and a computerized electrocardiogram was made by the ambulance nurses at the patient's home. Three electrocardiographic outcomes were available: 'normal electrocardiogram', 'possible myocardial infarction' or 'extensive myocardial infarction'. By use of the predictive model, the general practitioner could decide if hospitalization was necessary or not.\nMAIN OUTCOME MEASUREMENTS: Identification of patients at low (stable angina, atypical chest pain, other pathology) and high (myocardial infarction, unstable angina) probability of acute cardiac pathology.\nRESULTS: Among 977 patients with a complete pre-hospital evaluation in the validation phase of the study, the decision rule recommended 'no hospitalization' in 227 patients (23%). The general practitioner followed this advice in 44% of these patients. Although seven of them developed a non-Q wave myocardial infarction, no complications occurred in patients not admitted. In addition, the general practitioner did not hospitalize 19 (2%) of 750 patients for whom the decision rule recommended admission. Pre-hospital triage by the general practitioner resulted in a 12% (118 of 977 patients) reduction of the number of patients admitted to the Coronary Care Units.\nCONCLUSIONS: Pre-hospital triage by the general practitioner was facilitated using a standardized questionnaire and pre-hospital electrocardiography, and resulted in a reduction in the number of patients admitted to the Coronary Care Unit, and proved to be safe.","container-title":"European Heart Journal","ISSN":"0195-668X","issue":"1","journalAbbreviation":"Eur. Heart J.","language":"eng","note":"PMID: 8682136","page":"89-95","source":"PubMed","title":"Implementation of a pre-hospital decision rule in general practice. Triage of patients with suspected myocardial infarction","volume":"17","author":[{"family":"Grijseels","given":"E. W."},{"family":"Deckers","given":"J. W."},{"family":"Hoes","given":"A. W."},{"family":"Boersma","given":"E."},{"family":"Hartman","given":"J. A."},{"family":"Does","given":"E.","non-dropping-particle":"van der"},{"family":"Simoons","given":"M. L."}],"issued":{"date-parts":[["1996",1]]}}}],"schema":""} 16,30–35; six involving pre-hospital ECG interpretation ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"tgL246yL","properties":{"formattedCitation":"\\super 16,20,31,33\\uc0\\u8211{}35\\nosupersub{}","plainCitation":"16,20,31,33–35","noteIndex":0},"citationItems":[{"id":220,"uris":[""],"uri":[""],"itemData":{"id":220,"type":"article-journal","abstract":"OBJECTIVE: ST-elevation myocardial infarction (STEMI) identification by emergency medicine services (EMS) leading to pre-hospital catheterization laboratory (CL) activation shortens ischemic time and improves outcomes. We examined the incremental value of addition of a screening clinical tool (CT), containing clinical information and a Zoll electrocardiogram (ECG)-resident STEMI identification program (ZI) to ZI alone.\nMETHODS: All EMS-performed and ZI-analyzed ECGs transmitted to a percutaneous coronary intervention hospital from October 2009 to January 2011 were reviewed for diagnostic accuracy. ZI performance was also compared to ECG interpretations by 2 experienced readers The CT was then retrospectively applied to determine the incremental benefit above the ZI alone.\nRESULTS: ST-elevation myocardial infarction was confirmed in 23 (7.5%) of 305 patients. ZI was positive in 37 (12.1%): sensitivity: 95.6% and specificity: 94.6%, positive predictive value (PPV), 59.5%, negative predictive value (NPV), 99.6%, and accuracy of 93.8%. Moderate agreement was observed among the readers and ZI. CT criteria for CL activation were met in 24 (7.8%): 20 (83.3%) were confirmed STEMIs: sensitivity: 86.9%, specificity: 98.5%, a PPV: 83.3%, and NPV: 98.6%, accuracy of 97.7%. CT + ZI increased PPV (P<0.05) and specificity (P<0.003) by reducing false positive STEMI identifications from 15 (4.9%) to 4 (1.3%).\nCONCLUSIONS: In an urban cohort of all EMS transmitted ECGs, ZI has high sensitivity and specificity for STEMI identification. Whereas the PPV was low, reflecting both low STEMI prevalence and presence of STEMI-mimics, the NPV was very high. These findings suggest that a simplified CT combined with computer STEMI interpretation can identify patients for pre-hospital CL activation. Confirmation of these results could improve the design of STEMI care systems.","container-title":"The American Journal of Emergency Medicine","DOI":"10.1016/j.ajem.2013.04.013","ISSN":"1532-8171","issue":"7","journalAbbreviation":"Am J Emerg Med","language":"eng","note":"PMID: 23706572","page":"1098-1102","source":"PubMed","title":"An algorithm for identification of ST-elevation myocardial infarction patients by emergency medicine services","volume":"31","author":[{"family":"Wilson","given":"Ryan E."},{"family":"Kado","given":"Herman S."},{"family":"Percy","given":"Robert F."},{"family":"Butterfield","given":"Ryan C."},{"family":"Sabato","given":"Joseph"},{"family":"Strom","given":"Joel A."},{"family":"Box","given":"Lyndon C."}],"issued":{"date-parts":[["2013",7]]}}},{"id":445,"uris":[""],"uri":[""],"itemData":{"id":445,"type":"article-journal","abstract":"BACKGROUND: Identifying ST-segment elevation myocardial infarctions (STEMIs) in the field can decrease door-to-balloon times. Paramedics may use a computer algorithm to help them interpret prehospital electrocariograms (ECGs). It is unknown how accurately the computer can identify STEMIs.\nOBJECTIVES: To Determine the sensitivity and specificity of prehospital ECGs in identifying patients with STEMI.\nMETHODS: Retrospective cross-sectional study of 200 prehospital ECGs acquired using Lifepak 12 monitors and transmitted by one of more than 20 emergency medical services (EMS) agencies to the emergency department (ED) of a Summa Akron City Hospital, a level 1 trauma center between January 1, 2007, and February 18, 2010. The ED sees more than 73,000 adult patients and treats 120 STEMIs annually. The laboratory performs 3,400 catheterizations annually. The first 100 patients with a diagnosis of STEMI and cardiac catheterization laboratory activation from the ED were analyzed. For comparison, a control group of 100 other ECGs from patients without a STEMI were randomly selected from our Medtronic database using a random-number generator. For patients with STEMI, an accurate computer interpretation was \"acute MI suspected.\" Other interpretations were counted as misses. Specificity and sensitivity were calculated with confidence intervals (CIs). The sample size was determined a priori for a 95% CI of ±10%.\nRESULTS: Zero control patients were incorrectly labeled \"acute MI suspected.\" The specificity was 100% (100/100; 95% CI 0.96-1.0), whereas the sensitivity was 58% (58/100; 95% CI 0.48-0.67). This would have resulted in 42 missed cardiac catheterization laboratory activations, but zero inappropriate activations. The most common incorrect interpretation of STEMI ECGs by the computer was \"data quality prohibits interpretation,\" followed by \"abnormal ECG unconfirmed.\"\nCONCLUSIONS: Prehospital computer interpretation is not sensitive for STEMI identification and should not be used as a single method for prehospital activation of the cardiac catheterizing laboratory. Because of its high specificity, it may serve as an adjunct to interpretation.","container-title":"Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors","DOI":"10.3109/10903127.2012.722176","ISSN":"1545-0066","issue":"2","journalAbbreviation":"Prehosp Emerg Care","language":"eng","note":"PMID: 23066910","page":"211-216","source":"PubMed","title":"Prehospital electrocardiographic computer identification of ST-segment elevation myocardial infarction","volume":"17","author":[{"family":"Bhalla","given":"Mary Colleen"},{"family":"Mencl","given":"Francis"},{"family":"Gist","given":"Mikki Amber"},{"family":"Wilber","given":"Scott"},{"family":"Zalewski","given":"Jon"}],"issued":{"date-parts":[["2013",6]]}}},{"id":439,"uris":[""],"uri":[""],"itemData":{"id":439,"type":"article-journal","abstract":"BACKGROUND: The first study of the FamouS Triage project investigates the feasibility of ruling out a myocardial infarction in pre-hospital chest pain patients without electrocardiographic ST-segment elevation by using the modified HEART score at the patient's home, incorporating only a single highly sensitive troponin T measurement.\nMETHODS: A venous blood sample was drawn in the ambulance from 1127 consecutive chest pain patients for measurement of the pre-hospital highly sensitive troponin T levels, in order to establish a pre-hospital HEART score (i.e. the modified HEART score) and evaluate the possibility of triage at the patient's home. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) i.e. acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or death within 30 days after initial presentation.\nRESULTS: Two hundred and six patients (18%) developed a MACE during 30 days of follow-up. Thirty-six per cent of the patients ( n=403) had a low modified HEART score (0-3 points) and none of them developed a MACE during follow-up. Forty-four per cent of the patients ( n=494) had an intermediate modified HEART score (4-6 points) and 18% of them developed a MACE. Twenty per cent of the patients ( n=230) had a high modified HEART score (7-10 points) of which 52% developed a MACE during follow-up.\nCONCLUSION: It seems feasible to rule out a myocardial infarction at home in chest pain patients without ST-segment elevation by using the modified HEART score.\nTRIAL ID: NTR4205. Dutch Trial Register [ ]: trial number 4205.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872616687116","ISSN":"2048-8734","issue":"2","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 28084079","page":"102-110","source":"PubMed","title":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score","title-short":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage)","volume":"7","author":[{"family":"Ishak","given":"Maycel"},{"family":"Ali","given":"Danish"},{"family":"Fokkert","given":"Marion J."},{"family":"Slingerland","given":"Robbert J."},{"family":"Tolsma","given":"Rudolf T."},{"family":"Badings","given":"Erik"},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Eenennaam","given":"Fred","non-dropping-particle":"van"},{"family":"Mosterd","given":"Arend"},{"family":"Ten Berg","given":"Jurri?n M."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"}],"issued":{"date-parts":[["2018",3]]}}},{"id":437,"uris":[""],"uri":[""],"itemData":{"id":437,"type":"article-journal","abstract":"BACKGROUND: The purposes of this study were to create a new flow-chart of prehospital electrocardiography (ECG)-transmission, evaluate its predictive ability for ST-elevation myocardial infarction (STEMI) and shorten door-to-balloon time (DTBT).\nMETHOD AND RESULTS: The new transmission flow-chart was created using symptoms from previous medical records of STEMI patients. A total of 4090 consecutive patients transferred emergently to our hospital were divided into two groups: those in ambulances with an ECG-transmission device with the new flow-chart (ECGT-FC) and those transferred without an ECG-transmission device (non-ECGT) groups. A STEMI group comprising walk-in patients during the same period was used as a control group. The predictive ability of STEMI and the effectiveness of shortening the DTBT by the new flow-chart of ECG-transmission was evaluated. In the ECGT-FC group, the prevalence of STEMI in the ECG-transmission by the new flow-chart were significantly higher than in the non-ECG-transmission patients (6.71% vs. 0.19%; p<0.001). The sensitivity and specificity of the new ECG-transmission flow-chart were 83.3% and 88.1%, respectively. The median DTBT was significantly shortened (p=0.045) and the prevalence of DTBT<90min was significantly higher in the ECGT-FC group (p=0.018) than the other groups.\nCONCLUSION: The sensitivity and specificity of the new flow-chart for ECG-transmission were high. The new flow-chart combined with an ECG-transmission device could detect STEMI efficiently and shorten DTBT.","container-title":"Journal of Cardiology","DOI":"10.1016/j.jjcc.2018.03.011","ISSN":"1876-4738","issue":"4","journalAbbreviation":"J Cardiol","language":"eng","note":"PMID: 29804908","page":"335-342","source":"PubMed","title":"Predictive ability and efficacy for shortening door-to-balloon time of a new prehospital electrocardiogram-transmission flow chart in patients with ST-elevation myocardial infarction - Results of the CASSIOPEIA study","volume":"72","author":[{"family":"Sakai","given":"Toshiaki"},{"family":"Nishiyama","given":"Osamu"},{"family":"Onodera","given":"Masayuki"},{"family":"Matsuda","given":"Shigekatsu"},{"family":"Wakisawa","given":"Shinobu"},{"family":"Nakamura","given":"Motoyuki"},{"family":"Morino","given":"Yoshihiro"},{"family":"Itoh","given":"Tomonori"},{"literal":"CASSIOPEIA study group"}],"issued":{"date-parts":[["2018",10]]}}},{"id":435,"uris":[""],"uri":[""],"itemData":{"id":435,"type":"article-journal","abstract":"BACKGROUND:: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE).\nMETHODS:: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ? 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death.\nRESULTS:: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%).\nCONCLUSIONS:: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872618813846","ISSN":"2048-8734","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 30468395","page":"2048872618813846","source":"PubMed","title":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study","title-short":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome","author":[{"family":"Dongen","given":"Dominique N.","non-dropping-particle":"van"},{"family":"Tolsma","given":"Rudolf T."},{"family":"Fokkert","given":"Marion J."},{"family":"Badings","given":"Erik A."},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Slingerland","given":"Robbert J."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"},{"family":"Ottervanger","given":"Jan Paul"}],"issued":{"date-parts":[["2018",11,23]]}}},{"id":478,"uris":[""],"uri":[""],"itemData":{"id":478,"type":"article-journal","abstract":"OBJECTIVE: To improve pre-hospital triage of patients with suspected acute cardiac disease.\nDESIGN: Prospective study. SUBJECTS. Patients with symptoms suggestive of acute cardiac pathology, who were seen by a general practitioner, for whom acute admission into hospital was requested, and in whom a pre-hospital electrocardiogram was recorded by the ambulance service.\nMETHODS: The study consisted of two phases. In the first phase, a decision rule was developed based on clinical characteristics and electrocardiographic findings in 1005 patients with suspected acute cardiac pathology. In the second phase, the decision rule was prospectively validated. Symptoms were recorded by a standardized questionnaire by the general practitioner and a computerized electrocardiogram was made by the ambulance nurses at the patient's home. Three electrocardiographic outcomes were available: 'normal electrocardiogram', 'possible myocardial infarction' or 'extensive myocardial infarction'. By use of the predictive model, the general practitioner could decide if hospitalization was necessary or not.\nMAIN OUTCOME MEASUREMENTS: Identification of patients at low (stable angina, atypical chest pain, other pathology) and high (myocardial infarction, unstable angina) probability of acute cardiac pathology.\nRESULTS: Among 977 patients with a complete pre-hospital evaluation in the validation phase of the study, the decision rule recommended 'no hospitalization' in 227 patients (23%). The general practitioner followed this advice in 44% of these patients. Although seven of them developed a non-Q wave myocardial infarction, no complications occurred in patients not admitted. In addition, the general practitioner did not hospitalize 19 (2%) of 750 patients for whom the decision rule recommended admission. Pre-hospital triage by the general practitioner resulted in a 12% (118 of 977 patients) reduction of the number of patients admitted to the Coronary Care Units.\nCONCLUSIONS: Pre-hospital triage by the general practitioner was facilitated using a standardized questionnaire and pre-hospital electrocardiography, and resulted in a reduction in the number of patients admitted to the Coronary Care Unit, and proved to be safe.","container-title":"European Heart Journal","ISSN":"0195-668X","issue":"1","journalAbbreviation":"Eur. Heart J.","language":"eng","note":"PMID: 8682136","page":"89-95","source":"PubMed","title":"Implementation of a pre-hospital decision rule in general practice. Triage of patients with suspected myocardial infarction","volume":"17","author":[{"family":"Grijseels","given":"E. W."},{"family":"Deckers","given":"J. W."},{"family":"Hoes","given":"A. W."},{"family":"Boersma","given":"E."},{"family":"Hartman","given":"J. A."},{"family":"Does","given":"E.","non-dropping-particle":"van der"},{"family":"Simoons","given":"M. L."}],"issued":{"date-parts":[["1996",1]]}}}],"schema":""} 16,20,31,33–35; five involving examination and vital signs ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"baQduJaP","properties":{"formattedCitation":"\\super 16,31\\uc0\\u8211{}33,35\\nosupersub{}","plainCitation":"16,31–33,35","noteIndex":0},"citationItems":[{"id":439,"uris":[""],"uri":[""],"itemData":{"id":439,"type":"article-journal","abstract":"BACKGROUND: The first study of the FamouS Triage project investigates the feasibility of ruling out a myocardial infarction in pre-hospital chest pain patients without electrocardiographic ST-segment elevation by using the modified HEART score at the patient's home, incorporating only a single highly sensitive troponin T measurement.\nMETHODS: A venous blood sample was drawn in the ambulance from 1127 consecutive chest pain patients for measurement of the pre-hospital highly sensitive troponin T levels, in order to establish a pre-hospital HEART score (i.e. the modified HEART score) and evaluate the possibility of triage at the patient's home. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) i.e. acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or death within 30 days after initial presentation.\nRESULTS: Two hundred and six patients (18%) developed a MACE during 30 days of follow-up. Thirty-six per cent of the patients ( n=403) had a low modified HEART score (0-3 points) and none of them developed a MACE during follow-up. Forty-four per cent of the patients ( n=494) had an intermediate modified HEART score (4-6 points) and 18% of them developed a MACE. Twenty per cent of the patients ( n=230) had a high modified HEART score (7-10 points) of which 52% developed a MACE during follow-up.\nCONCLUSION: It seems feasible to rule out a myocardial infarction at home in chest pain patients without ST-segment elevation by using the modified HEART score.\nTRIAL ID: NTR4205. Dutch Trial Register [ ]: trial number 4205.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872616687116","ISSN":"2048-8734","issue":"2","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 28084079","page":"102-110","source":"PubMed","title":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score","title-short":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage)","volume":"7","author":[{"family":"Ishak","given":"Maycel"},{"family":"Ali","given":"Danish"},{"family":"Fokkert","given":"Marion J."},{"family":"Slingerland","given":"Robbert J."},{"family":"Tolsma","given":"Rudolf T."},{"family":"Badings","given":"Erik"},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Eenennaam","given":"Fred","non-dropping-particle":"van"},{"family":"Mosterd","given":"Arend"},{"family":"Ten Berg","given":"Jurri?n M."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"}],"issued":{"date-parts":[["2018",3]]}}},{"id":437,"uris":[""],"uri":[""],"itemData":{"id":437,"type":"article-journal","abstract":"BACKGROUND: The purposes of this study were to create a new flow-chart of prehospital electrocardiography (ECG)-transmission, evaluate its predictive ability for ST-elevation myocardial infarction (STEMI) and shorten door-to-balloon time (DTBT).\nMETHOD AND RESULTS: The new transmission flow-chart was created using symptoms from previous medical records of STEMI patients. A total of 4090 consecutive patients transferred emergently to our hospital were divided into two groups: those in ambulances with an ECG-transmission device with the new flow-chart (ECGT-FC) and those transferred without an ECG-transmission device (non-ECGT) groups. A STEMI group comprising walk-in patients during the same period was used as a control group. The predictive ability of STEMI and the effectiveness of shortening the DTBT by the new flow-chart of ECG-transmission was evaluated. In the ECGT-FC group, the prevalence of STEMI in the ECG-transmission by the new flow-chart were significantly higher than in the non-ECG-transmission patients (6.71% vs. 0.19%; p<0.001). The sensitivity and specificity of the new ECG-transmission flow-chart were 83.3% and 88.1%, respectively. The median DTBT was significantly shortened (p=0.045) and the prevalence of DTBT<90min was significantly higher in the ECGT-FC group (p=0.018) than the other groups.\nCONCLUSION: The sensitivity and specificity of the new flow-chart for ECG-transmission were high. The new flow-chart combined with an ECG-transmission device could detect STEMI efficiently and shorten DTBT.","container-title":"Journal of Cardiology","DOI":"10.1016/j.jjcc.2018.03.011","ISSN":"1876-4738","issue":"4","journalAbbreviation":"J Cardiol","language":"eng","note":"PMID: 29804908","page":"335-342","source":"PubMed","title":"Predictive ability and efficacy for shortening door-to-balloon time of a new prehospital electrocardiogram-transmission flow chart in patients with ST-elevation myocardial infarction - Results of the CASSIOPEIA study","volume":"72","author":[{"family":"Sakai","given":"Toshiaki"},{"family":"Nishiyama","given":"Osamu"},{"family":"Onodera","given":"Masayuki"},{"family":"Matsuda","given":"Shigekatsu"},{"family":"Wakisawa","given":"Shinobu"},{"family":"Nakamura","given":"Motoyuki"},{"family":"Morino","given":"Yoshihiro"},{"family":"Itoh","given":"Tomonori"},{"literal":"CASSIOPEIA study group"}],"issued":{"date-parts":[["2018",10]]}}},{"id":447,"uris":[""],"uri":[""],"itemData":{"id":447,"type":"article-journal","abstract":"BACKGROUND: Diagnosing acute coronary syndrome (ACS) in a primary care setting poses a diagnostic dilemma for physicians.\nOBJECTIVE: We directly compared the diagnostic accuracy of a clinical decision rule (CDR) based on history taking and physical examination in suspected ACS with the risk estimates of the attending GP.\nMETHODS: In a prospective multicenter study, patients suspected of ACS were included by the GP. GPs were asked to estimate the probability (0%-100%) of the presence of ACS. GPs collected patient data, but they were not aware of the CDR and did not score the patient accordingly.\nRESULTS: Two hundred and ninety-eight patients were included (52% female, mean age 66 years, 22% ACS). The area under the receiver operating characteristic (ROC) curve (AUC) was 0.75 [95% confidence interval (CI) 0.68-0.82] for the GP risk estimate and 0.66 (95% CI 0.58-0.73) for the CDR. There was an agreement between the risk estimation of the GP and a CDR in 51% and the prevalence of ACS in predefined low-, intermediate- and high-risk groups was similar for the GP and CDR estimates. In the low-risk group, according to the GP, four patients (8.2%) suffered an ACS. These four patients were all identified by the decision rule as high risk.\nCONCLUSIONS: The GP classified patients as ACS or no ACS more adequately than the CDR, judged by the AUC. However, the use of a CDR in patients that are considered at low risk for ACS by the GP could reduce the amount of missed myocardial infarctions.","container-title":"Family Practice","DOI":"10.1093/fampra/cmq116","ISSN":"1460-2229","issue":"3","journalAbbreviation":"Fam Pract","language":"eng","note":"PMID: 21239470","page":"323-328","source":"PubMed","title":"Diagnosing acute coronary syndrome in primary care: comparison of the physicians' risk estimation and a clinical decision rule","title-short":"Diagnosing acute coronary syndrome in primary care","volume":"28","author":[{"family":"Bruins Slot","given":"M. H. E."},{"family":"Rutten","given":"F. H."},{"family":"Heijden","given":"G. J. M. G.","non-dropping-particle":"van der"},{"family":"Geersing","given":"G. J."},{"family":"Glatz","given":"J. F. C."},{"family":"Hoes","given":"A. W."}],"issued":{"date-parts":[["2011",6]]}}},{"id":435,"uris":[""],"uri":[""],"itemData":{"id":435,"type":"article-journal","abstract":"BACKGROUND:: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE).\nMETHODS:: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ? 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death.\nRESULTS:: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%).\nCONCLUSIONS:: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872618813846","ISSN":"2048-8734","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 30468395","page":"2048872618813846","source":"PubMed","title":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study","title-short":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome","author":[{"family":"Dongen","given":"Dominique N.","non-dropping-particle":"van"},{"family":"Tolsma","given":"Rudolf T."},{"family":"Fokkert","given":"Marion J."},{"family":"Badings","given":"Erik A."},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Slingerland","given":"Robbert J."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"},{"family":"Ottervanger","given":"Jan Paul"}],"issued":{"date-parts":[["2018",11,23]]}}},{"id":478,"uris":[""],"uri":[""],"itemData":{"id":478,"type":"article-journal","abstract":"OBJECTIVE: To improve pre-hospital triage of patients with suspected acute cardiac disease.\nDESIGN: Prospective study. SUBJECTS. Patients with symptoms suggestive of acute cardiac pathology, who were seen by a general practitioner, for whom acute admission into hospital was requested, and in whom a pre-hospital electrocardiogram was recorded by the ambulance service.\nMETHODS: The study consisted of two phases. In the first phase, a decision rule was developed based on clinical characteristics and electrocardiographic findings in 1005 patients with suspected acute cardiac pathology. In the second phase, the decision rule was prospectively validated. Symptoms were recorded by a standardized questionnaire by the general practitioner and a computerized electrocardiogram was made by the ambulance nurses at the patient's home. Three electrocardiographic outcomes were available: 'normal electrocardiogram', 'possible myocardial infarction' or 'extensive myocardial infarction'. By use of the predictive model, the general practitioner could decide if hospitalization was necessary or not.\nMAIN OUTCOME MEASUREMENTS: Identification of patients at low (stable angina, atypical chest pain, other pathology) and high (myocardial infarction, unstable angina) probability of acute cardiac pathology.\nRESULTS: Among 977 patients with a complete pre-hospital evaluation in the validation phase of the study, the decision rule recommended 'no hospitalization' in 227 patients (23%). The general practitioner followed this advice in 44% of these patients. Although seven of them developed a non-Q wave myocardial infarction, no complications occurred in patients not admitted. In addition, the general practitioner did not hospitalize 19 (2%) of 750 patients for whom the decision rule recommended admission. Pre-hospital triage by the general practitioner resulted in a 12% (118 of 977 patients) reduction of the number of patients admitted to the Coronary Care Units.\nCONCLUSIONS: Pre-hospital triage by the general practitioner was facilitated using a standardized questionnaire and pre-hospital electrocardiography, and resulted in a reduction in the number of patients admitted to the Coronary Care Unit, and proved to be safe.","container-title":"European Heart Journal","ISSN":"0195-668X","issue":"1","journalAbbreviation":"Eur. Heart J.","language":"eng","note":"PMID: 8682136","page":"89-95","source":"PubMed","title":"Implementation of a pre-hospital decision rule in general practice. Triage of patients with suspected myocardial infarction","volume":"17","author":[{"family":"Grijseels","given":"E. W."},{"family":"Deckers","given":"J. W."},{"family":"Hoes","given":"A. W."},{"family":"Boersma","given":"E."},{"family":"Hartman","given":"J. A."},{"family":"Does","given":"E.","non-dropping-particle":"van der"},{"family":"Simoons","given":"M. L."}],"issued":{"date-parts":[["1996",1]]}}}],"schema":""} 16,31–33,35; and two involving a pre-hospital biomarker test ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"3FnaeCVL","properties":{"formattedCitation":"\\super 16,35\\nosupersub{}","plainCitation":"16,35","noteIndex":0},"citationItems":[{"id":439,"uris":[""],"uri":[""],"itemData":{"id":439,"type":"article-journal","abstract":"BACKGROUND: The first study of the FamouS Triage project investigates the feasibility of ruling out a myocardial infarction in pre-hospital chest pain patients without electrocardiographic ST-segment elevation by using the modified HEART score at the patient's home, incorporating only a single highly sensitive troponin T measurement.\nMETHODS: A venous blood sample was drawn in the ambulance from 1127 consecutive chest pain patients for measurement of the pre-hospital highly sensitive troponin T levels, in order to establish a pre-hospital HEART score (i.e. the modified HEART score) and evaluate the possibility of triage at the patient's home. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) i.e. acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or death within 30 days after initial presentation.\nRESULTS: Two hundred and six patients (18%) developed a MACE during 30 days of follow-up. Thirty-six per cent of the patients ( n=403) had a low modified HEART score (0-3 points) and none of them developed a MACE during follow-up. Forty-four per cent of the patients ( n=494) had an intermediate modified HEART score (4-6 points) and 18% of them developed a MACE. Twenty per cent of the patients ( n=230) had a high modified HEART score (7-10 points) of which 52% developed a MACE during follow-up.\nCONCLUSION: It seems feasible to rule out a myocardial infarction at home in chest pain patients without ST-segment elevation by using the modified HEART score.\nTRIAL ID: NTR4205. Dutch Trial Register [ ]: trial number 4205.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872616687116","ISSN":"2048-8734","issue":"2","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 28084079","page":"102-110","source":"PubMed","title":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score","title-short":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage)","volume":"7","author":[{"family":"Ishak","given":"Maycel"},{"family":"Ali","given":"Danish"},{"family":"Fokkert","given":"Marion J."},{"family":"Slingerland","given":"Robbert J."},{"family":"Tolsma","given":"Rudolf T."},{"family":"Badings","given":"Erik"},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Eenennaam","given":"Fred","non-dropping-particle":"van"},{"family":"Mosterd","given":"Arend"},{"family":"Ten Berg","given":"Jurri?n M."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"}],"issued":{"date-parts":[["2018",3]]}}},{"id":435,"uris":[""],"uri":[""],"itemData":{"id":435,"type":"article-journal","abstract":"BACKGROUND:: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE).\nMETHODS:: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ? 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death.\nRESULTS:: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%).\nCONCLUSIONS:: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872618813846","ISSN":"2048-8734","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 30468395","page":"2048872618813846","source":"PubMed","title":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study","title-short":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome","author":[{"family":"Dongen","given":"Dominique N.","non-dropping-particle":"van"},{"family":"Tolsma","given":"Rudolf T."},{"family":"Fokkert","given":"Marion J."},{"family":"Badings","given":"Erik A."},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Slingerland","given":"Robbert J."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"},{"family":"Ottervanger","given":"Jan Paul"}],"issued":{"date-parts":[["2018",11,23]]}}}],"schema":""} 16,35. The last two studies were the only ones to develop CDSS that incorporated all four components ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"imaIAJk6","properties":{"formattedCitation":"\\super 16,35\\nosupersub{}","plainCitation":"16,35","noteIndex":0},"citationItems":[{"id":439,"uris":[""],"uri":[""],"itemData":{"id":439,"type":"article-journal","abstract":"BACKGROUND: The first study of the FamouS Triage project investigates the feasibility of ruling out a myocardial infarction in pre-hospital chest pain patients without electrocardiographic ST-segment elevation by using the modified HEART score at the patient's home, incorporating only a single highly sensitive troponin T measurement.\nMETHODS: A venous blood sample was drawn in the ambulance from 1127 consecutive chest pain patients for measurement of the pre-hospital highly sensitive troponin T levels, in order to establish a pre-hospital HEART score (i.e. the modified HEART score) and evaluate the possibility of triage at the patient's home. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) i.e. acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or death within 30 days after initial presentation.\nRESULTS: Two hundred and six patients (18%) developed a MACE during 30 days of follow-up. Thirty-six per cent of the patients ( n=403) had a low modified HEART score (0-3 points) and none of them developed a MACE during follow-up. Forty-four per cent of the patients ( n=494) had an intermediate modified HEART score (4-6 points) and 18% of them developed a MACE. Twenty per cent of the patients ( n=230) had a high modified HEART score (7-10 points) of which 52% developed a MACE during follow-up.\nCONCLUSION: It seems feasible to rule out a myocardial infarction at home in chest pain patients without ST-segment elevation by using the modified HEART score.\nTRIAL ID: NTR4205. Dutch Trial Register [ ]: trial number 4205.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872616687116","ISSN":"2048-8734","issue":"2","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 28084079","page":"102-110","source":"PubMed","title":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score","title-short":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage)","volume":"7","author":[{"family":"Ishak","given":"Maycel"},{"family":"Ali","given":"Danish"},{"family":"Fokkert","given":"Marion J."},{"family":"Slingerland","given":"Robbert J."},{"family":"Tolsma","given":"Rudolf T."},{"family":"Badings","given":"Erik"},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Eenennaam","given":"Fred","non-dropping-particle":"van"},{"family":"Mosterd","given":"Arend"},{"family":"Ten Berg","given":"Jurri?n M."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"}],"issued":{"date-parts":[["2018",3]]}}},{"id":435,"uris":[""],"uri":[""],"itemData":{"id":435,"type":"article-journal","abstract":"BACKGROUND:: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE).\nMETHODS:: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ? 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death.\nRESULTS:: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%).\nCONCLUSIONS:: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872618813846","ISSN":"2048-8734","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 30468395","page":"2048872618813846","source":"PubMed","title":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study","title-short":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome","author":[{"family":"Dongen","given":"Dominique N.","non-dropping-particle":"van"},{"family":"Tolsma","given":"Rudolf T."},{"family":"Fokkert","given":"Marion J."},{"family":"Badings","given":"Erik A."},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Slingerland","given":"Robbert J."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"},{"family":"Ottervanger","given":"Jan Paul"}],"issued":{"date-parts":[["2018",11,23]]}}}],"schema":""} 16,35. With regards to the outcomes measured, three reported ACS (MI including unstable angina) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"uEPvDCrV","properties":{"formattedCitation":"\\super 30,32,33\\nosupersub{}","plainCitation":"30,32,33","noteIndex":0},"citationItems":[{"id":441,"uris":[""],"uri":[""],"itemData":{"id":441,"type":"article-journal","abstract":"BACKGROUND: To evaluate whether a computer-based decision support system could improve the allocation of patients with acute coronary syndrome (ACS) or a life-threatening condition (LTC). We hypothesised that a system of this kind would improve sensitivity without compromising specificity.\nMETHODS: A total of 2285 consecutive patients who dialed 112 due to chest pain were asked 10 specific questions and a prediction model was constructed based on the answers. We compared the sensitivity of the dispatchers' decisions with that of the model-based decision support model.\nRESULTS: A total of 2048 patients answered all 10 questions. Among the 235 patients with ACS, 194 were allocated the highest prioritisation by dispatchers (sensitivity 82.6%) and 41 patients were given a lower prioritisation (17.4% false negatives). The allocation suggested by the model used the highest prioritisation in 212 of the patients with ACS (sensitivity of 90.2%), while 23 patients were underprioritised (9.8% false negatives). The results were similar when the two systems were compared with regard to LTC and 30-day mortality. This indicates that computer-based decision support could be used either for increasing sensitivity or for saving resources. Three questions proved to be most important in terms of predicting ACS/LTC, [1] the intensity of pain, [2] the localisation of pain and [3] a history of ACS.\nCONCLUSION: Among patients with acute chest pain, computer-based decision support with a model based on a few fundamental questions could improve sensitivity and reduce the number of cases with the highest prioritisation without endangering the patients.","container-title":"International Journal of Cardiology","DOI":"10.1016/j.ijcard.2016.06.281","ISSN":"1874-1754","journalAbbreviation":"Int. J. Cardiol.","language":"eng","note":"PMID: 27393857","page":"734-738","source":"PubMed","title":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support? A cohort of patients with chest pain","title-short":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support?","volume":"220","author":[{"family":"Gellerstedt","given":"Martin"},{"family":"Rawshani","given":"Nina"},{"family":"Herlitz","given":"Johan"},{"family":"B?ng","given":"Angela"},{"family":"Gelang","given":"Carita"},{"family":"Andersson","given":"Jan-Otto"},{"family":"Larsson","given":"Anna"},{"family":"Rawshani","given":"Araz"}],"issued":{"date-parts":[["2016",10,1]]}}},{"id":447,"uris":[""],"uri":[""],"itemData":{"id":447,"type":"article-journal","abstract":"BACKGROUND: Diagnosing acute coronary syndrome (ACS) in a primary care setting poses a diagnostic dilemma for physicians.\nOBJECTIVE: We directly compared the diagnostic accuracy of a clinical decision rule (CDR) based on history taking and physical examination in suspected ACS with the risk estimates of the attending GP.\nMETHODS: In a prospective multicenter study, patients suspected of ACS were included by the GP. GPs were asked to estimate the probability (0%-100%) of the presence of ACS. GPs collected patient data, but they were not aware of the CDR and did not score the patient accordingly.\nRESULTS: Two hundred and ninety-eight patients were included (52% female, mean age 66 years, 22% ACS). The area under the receiver operating characteristic (ROC) curve (AUC) was 0.75 [95% confidence interval (CI) 0.68-0.82] for the GP risk estimate and 0.66 (95% CI 0.58-0.73) for the CDR. There was an agreement between the risk estimation of the GP and a CDR in 51% and the prevalence of ACS in predefined low-, intermediate- and high-risk groups was similar for the GP and CDR estimates. In the low-risk group, according to the GP, four patients (8.2%) suffered an ACS. These four patients were all identified by the decision rule as high risk.\nCONCLUSIONS: The GP classified patients as ACS or no ACS more adequately than the CDR, judged by the AUC. However, the use of a CDR in patients that are considered at low risk for ACS by the GP could reduce the amount of missed myocardial infarctions.","container-title":"Family Practice","DOI":"10.1093/fampra/cmq116","ISSN":"1460-2229","issue":"3","journalAbbreviation":"Fam Pract","language":"eng","note":"PMID: 21239470","page":"323-328","source":"PubMed","title":"Diagnosing acute coronary syndrome in primary care: comparison of the physicians' risk estimation and a clinical decision rule","title-short":"Diagnosing acute coronary syndrome in primary care","volume":"28","author":[{"family":"Bruins Slot","given":"M. H. E."},{"family":"Rutten","given":"F. H."},{"family":"Heijden","given":"G. J. M. G.","non-dropping-particle":"van der"},{"family":"Geersing","given":"G. J."},{"family":"Glatz","given":"J. F. C."},{"family":"Hoes","given":"A. W."}],"issued":{"date-parts":[["2011",6]]}}},{"id":478,"uris":[""],"uri":[""],"itemData":{"id":478,"type":"article-journal","abstract":"OBJECTIVE: To improve pre-hospital triage of patients with suspected acute cardiac disease.\nDESIGN: Prospective study. SUBJECTS. Patients with symptoms suggestive of acute cardiac pathology, who were seen by a general practitioner, for whom acute admission into hospital was requested, and in whom a pre-hospital electrocardiogram was recorded by the ambulance service.\nMETHODS: The study consisted of two phases. In the first phase, a decision rule was developed based on clinical characteristics and electrocardiographic findings in 1005 patients with suspected acute cardiac pathology. In the second phase, the decision rule was prospectively validated. Symptoms were recorded by a standardized questionnaire by the general practitioner and a computerized electrocardiogram was made by the ambulance nurses at the patient's home. Three electrocardiographic outcomes were available: 'normal electrocardiogram', 'possible myocardial infarction' or 'extensive myocardial infarction'. By use of the predictive model, the general practitioner could decide if hospitalization was necessary or not.\nMAIN OUTCOME MEASUREMENTS: Identification of patients at low (stable angina, atypical chest pain, other pathology) and high (myocardial infarction, unstable angina) probability of acute cardiac pathology.\nRESULTS: Among 977 patients with a complete pre-hospital evaluation in the validation phase of the study, the decision rule recommended 'no hospitalization' in 227 patients (23%). The general practitioner followed this advice in 44% of these patients. Although seven of them developed a non-Q wave myocardial infarction, no complications occurred in patients not admitted. In addition, the general practitioner did not hospitalize 19 (2%) of 750 patients for whom the decision rule recommended admission. Pre-hospital triage by the general practitioner resulted in a 12% (118 of 977 patients) reduction of the number of patients admitted to the Coronary Care Units.\nCONCLUSIONS: Pre-hospital triage by the general practitioner was facilitated using a standardized questionnaire and pre-hospital electrocardiography, and resulted in a reduction in the number of patients admitted to the Coronary Care Unit, and proved to be safe.","container-title":"European Heart Journal","ISSN":"0195-668X","issue":"1","journalAbbreviation":"Eur. Heart J.","language":"eng","note":"PMID: 8682136","page":"89-95","source":"PubMed","title":"Implementation of a pre-hospital decision rule in general practice. Triage of patients with suspected myocardial infarction","volume":"17","author":[{"family":"Grijseels","given":"E. W."},{"family":"Deckers","given":"J. W."},{"family":"Hoes","given":"A. W."},{"family":"Boersma","given":"E."},{"family":"Hartman","given":"J. A."},{"family":"Does","given":"E.","non-dropping-particle":"van der"},{"family":"Simoons","given":"M. L."}],"issued":{"date-parts":[["1996",1]]}}}],"schema":""} 30,32,33; three others reported STEMI ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"R653IFDm","properties":{"formattedCitation":"\\super 20,31,34\\nosupersub{}","plainCitation":"20,31,34","noteIndex":0},"citationItems":[{"id":220,"uris":[""],"uri":[""],"itemData":{"id":220,"type":"article-journal","abstract":"OBJECTIVE: ST-elevation myocardial infarction (STEMI) identification by emergency medicine services (EMS) leading to pre-hospital catheterization laboratory (CL) activation shortens ischemic time and improves outcomes. We examined the incremental value of addition of a screening clinical tool (CT), containing clinical information and a Zoll electrocardiogram (ECG)-resident STEMI identification program (ZI) to ZI alone.\nMETHODS: All EMS-performed and ZI-analyzed ECGs transmitted to a percutaneous coronary intervention hospital from October 2009 to January 2011 were reviewed for diagnostic accuracy. ZI performance was also compared to ECG interpretations by 2 experienced readers The CT was then retrospectively applied to determine the incremental benefit above the ZI alone.\nRESULTS: ST-elevation myocardial infarction was confirmed in 23 (7.5%) of 305 patients. ZI was positive in 37 (12.1%): sensitivity: 95.6% and specificity: 94.6%, positive predictive value (PPV), 59.5%, negative predictive value (NPV), 99.6%, and accuracy of 93.8%. Moderate agreement was observed among the readers and ZI. CT criteria for CL activation were met in 24 (7.8%): 20 (83.3%) were confirmed STEMIs: sensitivity: 86.9%, specificity: 98.5%, a PPV: 83.3%, and NPV: 98.6%, accuracy of 97.7%. CT + ZI increased PPV (P<0.05) and specificity (P<0.003) by reducing false positive STEMI identifications from 15 (4.9%) to 4 (1.3%).\nCONCLUSIONS: In an urban cohort of all EMS transmitted ECGs, ZI has high sensitivity and specificity for STEMI identification. Whereas the PPV was low, reflecting both low STEMI prevalence and presence of STEMI-mimics, the NPV was very high. These findings suggest that a simplified CT combined with computer STEMI interpretation can identify patients for pre-hospital CL activation. Confirmation of these results could improve the design of STEMI care systems.","container-title":"The American Journal of Emergency Medicine","DOI":"10.1016/j.ajem.2013.04.013","ISSN":"1532-8171","issue":"7","journalAbbreviation":"Am J Emerg Med","language":"eng","note":"PMID: 23706572","page":"1098-1102","source":"PubMed","title":"An algorithm for identification of ST-elevation myocardial infarction patients by emergency medicine services","volume":"31","author":[{"family":"Wilson","given":"Ryan E."},{"family":"Kado","given":"Herman S."},{"family":"Percy","given":"Robert F."},{"family":"Butterfield","given":"Ryan C."},{"family":"Sabato","given":"Joseph"},{"family":"Strom","given":"Joel A."},{"family":"Box","given":"Lyndon C."}],"issued":{"date-parts":[["2013",7]]}}},{"id":445,"uris":[""],"uri":[""],"itemData":{"id":445,"type":"article-journal","abstract":"BACKGROUND: Identifying ST-segment elevation myocardial infarctions (STEMIs) in the field can decrease door-to-balloon times. Paramedics may use a computer algorithm to help them interpret prehospital electrocariograms (ECGs). It is unknown how accurately the computer can identify STEMIs.\nOBJECTIVES: To Determine the sensitivity and specificity of prehospital ECGs in identifying patients with STEMI.\nMETHODS: Retrospective cross-sectional study of 200 prehospital ECGs acquired using Lifepak 12 monitors and transmitted by one of more than 20 emergency medical services (EMS) agencies to the emergency department (ED) of a Summa Akron City Hospital, a level 1 trauma center between January 1, 2007, and February 18, 2010. The ED sees more than 73,000 adult patients and treats 120 STEMIs annually. The laboratory performs 3,400 catheterizations annually. The first 100 patients with a diagnosis of STEMI and cardiac catheterization laboratory activation from the ED were analyzed. For comparison, a control group of 100 other ECGs from patients without a STEMI were randomly selected from our Medtronic database using a random-number generator. For patients with STEMI, an accurate computer interpretation was \"acute MI suspected.\" Other interpretations were counted as misses. Specificity and sensitivity were calculated with confidence intervals (CIs). The sample size was determined a priori for a 95% CI of ±10%.\nRESULTS: Zero control patients were incorrectly labeled \"acute MI suspected.\" The specificity was 100% (100/100; 95% CI 0.96-1.0), whereas the sensitivity was 58% (58/100; 95% CI 0.48-0.67). This would have resulted in 42 missed cardiac catheterization laboratory activations, but zero inappropriate activations. The most common incorrect interpretation of STEMI ECGs by the computer was \"data quality prohibits interpretation,\" followed by \"abnormal ECG unconfirmed.\"\nCONCLUSIONS: Prehospital computer interpretation is not sensitive for STEMI identification and should not be used as a single method for prehospital activation of the cardiac catheterizing laboratory. Because of its high specificity, it may serve as an adjunct to interpretation.","container-title":"Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors","DOI":"10.3109/10903127.2012.722176","ISSN":"1545-0066","issue":"2","journalAbbreviation":"Prehosp Emerg Care","language":"eng","note":"PMID: 23066910","page":"211-216","source":"PubMed","title":"Prehospital electrocardiographic computer identification of ST-segment elevation myocardial infarction","volume":"17","author":[{"family":"Bhalla","given":"Mary Colleen"},{"family":"Mencl","given":"Francis"},{"family":"Gist","given":"Mikki Amber"},{"family":"Wilber","given":"Scott"},{"family":"Zalewski","given":"Jon"}],"issued":{"date-parts":[["2013",6]]}}},{"id":437,"uris":[""],"uri":[""],"itemData":{"id":437,"type":"article-journal","abstract":"BACKGROUND: The purposes of this study were to create a new flow-chart of prehospital electrocardiography (ECG)-transmission, evaluate its predictive ability for ST-elevation myocardial infarction (STEMI) and shorten door-to-balloon time (DTBT).\nMETHOD AND RESULTS: The new transmission flow-chart was created using symptoms from previous medical records of STEMI patients. A total of 4090 consecutive patients transferred emergently to our hospital were divided into two groups: those in ambulances with an ECG-transmission device with the new flow-chart (ECGT-FC) and those transferred without an ECG-transmission device (non-ECGT) groups. A STEMI group comprising walk-in patients during the same period was used as a control group. The predictive ability of STEMI and the effectiveness of shortening the DTBT by the new flow-chart of ECG-transmission was evaluated. In the ECGT-FC group, the prevalence of STEMI in the ECG-transmission by the new flow-chart were significantly higher than in the non-ECG-transmission patients (6.71% vs. 0.19%; p<0.001). The sensitivity and specificity of the new ECG-transmission flow-chart were 83.3% and 88.1%, respectively. The median DTBT was significantly shortened (p=0.045) and the prevalence of DTBT<90min was significantly higher in the ECGT-FC group (p=0.018) than the other groups.\nCONCLUSION: The sensitivity and specificity of the new flow-chart for ECG-transmission were high. The new flow-chart combined with an ECG-transmission device could detect STEMI efficiently and shorten DTBT.","container-title":"Journal of Cardiology","DOI":"10.1016/j.jjcc.2018.03.011","ISSN":"1876-4738","issue":"4","journalAbbreviation":"J Cardiol","language":"eng","note":"PMID: 29804908","page":"335-342","source":"PubMed","title":"Predictive ability and efficacy for shortening door-to-balloon time of a new prehospital electrocardiogram-transmission flow chart in patients with ST-elevation myocardial infarction - Results of the CASSIOPEIA study","volume":"72","author":[{"family":"Sakai","given":"Toshiaki"},{"family":"Nishiyama","given":"Osamu"},{"family":"Onodera","given":"Masayuki"},{"family":"Matsuda","given":"Shigekatsu"},{"family":"Wakisawa","given":"Shinobu"},{"family":"Nakamura","given":"Motoyuki"},{"family":"Morino","given":"Yoshihiro"},{"family":"Itoh","given":"Tomonori"},{"literal":"CASSIOPEIA study group"}],"issued":{"date-parts":[["2018",10]]}}}],"schema":""} 20,31,34; one reported NSTEMI ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"SSze21iV","properties":{"formattedCitation":"\\super 16\\nosupersub{}","plainCitation":"16","noteIndex":0},"citationItems":[{"id":435,"uris":[""],"uri":[""],"itemData":{"id":435,"type":"article-journal","abstract":"BACKGROUND:: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE).\nMETHODS:: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ? 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death.\nRESULTS:: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%).\nCONCLUSIONS:: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872618813846","ISSN":"2048-8734","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 30468395","page":"2048872618813846","source":"PubMed","title":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study","title-short":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome","author":[{"family":"Dongen","given":"Dominique N.","non-dropping-particle":"van"},{"family":"Tolsma","given":"Rudolf T."},{"family":"Fokkert","given":"Marion J."},{"family":"Badings","given":"Erik A."},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Slingerland","given":"Robbert J."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"},{"family":"Ottervanger","given":"Jan Paul"}],"issued":{"date-parts":[["2018",11,23]]}}}],"schema":""} 16; and one reported a major adverse cardiovascular event ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"qE2ntyFe","properties":{"formattedCitation":"\\super 35\\nosupersub{}","plainCitation":"35","noteIndex":0},"citationItems":[{"id":439,"uris":[""],"uri":[""],"itemData":{"id":439,"type":"article-journal","abstract":"BACKGROUND: The first study of the FamouS Triage project investigates the feasibility of ruling out a myocardial infarction in pre-hospital chest pain patients without electrocardiographic ST-segment elevation by using the modified HEART score at the patient's home, incorporating only a single highly sensitive troponin T measurement.\nMETHODS: A venous blood sample was drawn in the ambulance from 1127 consecutive chest pain patients for measurement of the pre-hospital highly sensitive troponin T levels, in order to establish a pre-hospital HEART score (i.e. the modified HEART score) and evaluate the possibility of triage at the patient's home. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) i.e. acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or death within 30 days after initial presentation.\nRESULTS: Two hundred and six patients (18%) developed a MACE during 30 days of follow-up. Thirty-six per cent of the patients ( n=403) had a low modified HEART score (0-3 points) and none of them developed a MACE during follow-up. Forty-four per cent of the patients ( n=494) had an intermediate modified HEART score (4-6 points) and 18% of them developed a MACE. Twenty per cent of the patients ( n=230) had a high modified HEART score (7-10 points) of which 52% developed a MACE during follow-up.\nCONCLUSION: It seems feasible to rule out a myocardial infarction at home in chest pain patients without ST-segment elevation by using the modified HEART score.\nTRIAL ID: NTR4205. Dutch Trial Register [ ]: trial number 4205.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872616687116","ISSN":"2048-8734","issue":"2","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 28084079","page":"102-110","source":"PubMed","title":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score","title-short":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage)","volume":"7","author":[{"family":"Ishak","given":"Maycel"},{"family":"Ali","given":"Danish"},{"family":"Fokkert","given":"Marion J."},{"family":"Slingerland","given":"Robbert J."},{"family":"Tolsma","given":"Rudolf T."},{"family":"Badings","given":"Erik"},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Eenennaam","given":"Fred","non-dropping-particle":"van"},{"family":"Mosterd","given":"Arend"},{"family":"Ten Berg","given":"Jurri?n M."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"}],"issued":{"date-parts":[["2018",3]]}}}],"schema":""} 35(defined as any MI, primary PCI, coronary artery bypass graft or any cause of mortality). The definition of MI also differed between studies, with three ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"x9VFnBSM","properties":{"formattedCitation":"\\super 30,32,34\\nosupersub{}","plainCitation":"30,32,34","noteIndex":0},"citationItems":[{"id":441,"uris":[""],"uri":[""],"itemData":{"id":441,"type":"article-journal","abstract":"BACKGROUND: To evaluate whether a computer-based decision support system could improve the allocation of patients with acute coronary syndrome (ACS) or a life-threatening condition (LTC). We hypothesised that a system of this kind would improve sensitivity without compromising specificity.\nMETHODS: A total of 2285 consecutive patients who dialed 112 due to chest pain were asked 10 specific questions and a prediction model was constructed based on the answers. We compared the sensitivity of the dispatchers' decisions with that of the model-based decision support model.\nRESULTS: A total of 2048 patients answered all 10 questions. Among the 235 patients with ACS, 194 were allocated the highest prioritisation by dispatchers (sensitivity 82.6%) and 41 patients were given a lower prioritisation (17.4% false negatives). The allocation suggested by the model used the highest prioritisation in 212 of the patients with ACS (sensitivity of 90.2%), while 23 patients were underprioritised (9.8% false negatives). The results were similar when the two systems were compared with regard to LTC and 30-day mortality. This indicates that computer-based decision support could be used either for increasing sensitivity or for saving resources. Three questions proved to be most important in terms of predicting ACS/LTC, [1] the intensity of pain, [2] the localisation of pain and [3] a history of ACS.\nCONCLUSION: Among patients with acute chest pain, computer-based decision support with a model based on a few fundamental questions could improve sensitivity and reduce the number of cases with the highest prioritisation without endangering the patients.","container-title":"International Journal of Cardiology","DOI":"10.1016/j.ijcard.2016.06.281","ISSN":"1874-1754","journalAbbreviation":"Int. J. Cardiol.","language":"eng","note":"PMID: 27393857","page":"734-738","source":"PubMed","title":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support? A cohort of patients with chest pain","title-short":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support?","volume":"220","author":[{"family":"Gellerstedt","given":"Martin"},{"family":"Rawshani","given":"Nina"},{"family":"Herlitz","given":"Johan"},{"family":"B?ng","given":"Angela"},{"family":"Gelang","given":"Carita"},{"family":"Andersson","given":"Jan-Otto"},{"family":"Larsson","given":"Anna"},{"family":"Rawshani","given":"Araz"}],"issued":{"date-parts":[["2016",10,1]]}}},{"id":220,"uris":[""],"uri":[""],"itemData":{"id":220,"type":"article-journal","abstract":"OBJECTIVE: ST-elevation myocardial infarction (STEMI) identification by emergency medicine services (EMS) leading to pre-hospital catheterization laboratory (CL) activation shortens ischemic time and improves outcomes. We examined the incremental value of addition of a screening clinical tool (CT), containing clinical information and a Zoll electrocardiogram (ECG)-resident STEMI identification program (ZI) to ZI alone.\nMETHODS: All EMS-performed and ZI-analyzed ECGs transmitted to a percutaneous coronary intervention hospital from October 2009 to January 2011 were reviewed for diagnostic accuracy. ZI performance was also compared to ECG interpretations by 2 experienced readers The CT was then retrospectively applied to determine the incremental benefit above the ZI alone.\nRESULTS: ST-elevation myocardial infarction was confirmed in 23 (7.5%) of 305 patients. ZI was positive in 37 (12.1%): sensitivity: 95.6% and specificity: 94.6%, positive predictive value (PPV), 59.5%, negative predictive value (NPV), 99.6%, and accuracy of 93.8%. Moderate agreement was observed among the readers and ZI. CT criteria for CL activation were met in 24 (7.8%): 20 (83.3%) were confirmed STEMIs: sensitivity: 86.9%, specificity: 98.5%, a PPV: 83.3%, and NPV: 98.6%, accuracy of 97.7%. CT + ZI increased PPV (P<0.05) and specificity (P<0.003) by reducing false positive STEMI identifications from 15 (4.9%) to 4 (1.3%).\nCONCLUSIONS: In an urban cohort of all EMS transmitted ECGs, ZI has high sensitivity and specificity for STEMI identification. Whereas the PPV was low, reflecting both low STEMI prevalence and presence of STEMI-mimics, the NPV was very high. These findings suggest that a simplified CT combined with computer STEMI interpretation can identify patients for pre-hospital CL activation. Confirmation of these results could improve the design of STEMI care systems.","container-title":"The American Journal of Emergency Medicine","DOI":"10.1016/j.ajem.2013.04.013","ISSN":"1532-8171","issue":"7","journalAbbreviation":"Am J Emerg Med","language":"eng","note":"PMID: 23706572","page":"1098-1102","source":"PubMed","title":"An algorithm for identification of ST-elevation myocardial infarction patients by emergency medicine services","volume":"31","author":[{"family":"Wilson","given":"Ryan E."},{"family":"Kado","given":"Herman S."},{"family":"Percy","given":"Robert F."},{"family":"Butterfield","given":"Ryan C."},{"family":"Sabato","given":"Joseph"},{"family":"Strom","given":"Joel A."},{"family":"Box","given":"Lyndon C."}],"issued":{"date-parts":[["2013",7]]}}},{"id":447,"uris":[""],"uri":[""],"itemData":{"id":447,"type":"article-journal","abstract":"BACKGROUND: Diagnosing acute coronary syndrome (ACS) in a primary care setting poses a diagnostic dilemma for physicians.\nOBJECTIVE: We directly compared the diagnostic accuracy of a clinical decision rule (CDR) based on history taking and physical examination in suspected ACS with the risk estimates of the attending GP.\nMETHODS: In a prospective multicenter study, patients suspected of ACS were included by the GP. GPs were asked to estimate the probability (0%-100%) of the presence of ACS. GPs collected patient data, but they were not aware of the CDR and did not score the patient accordingly.\nRESULTS: Two hundred and ninety-eight patients were included (52% female, mean age 66 years, 22% ACS). The area under the receiver operating characteristic (ROC) curve (AUC) was 0.75 [95% confidence interval (CI) 0.68-0.82] for the GP risk estimate and 0.66 (95% CI 0.58-0.73) for the CDR. There was an agreement between the risk estimation of the GP and a CDR in 51% and the prevalence of ACS in predefined low-, intermediate- and high-risk groups was similar for the GP and CDR estimates. In the low-risk group, according to the GP, four patients (8.2%) suffered an ACS. These four patients were all identified by the decision rule as high risk.\nCONCLUSIONS: The GP classified patients as ACS or no ACS more adequately than the CDR, judged by the AUC. However, the use of a CDR in patients that are considered at low risk for ACS by the GP could reduce the amount of missed myocardial infarctions.","container-title":"Family Practice","DOI":"10.1093/fampra/cmq116","ISSN":"1460-2229","issue":"3","journalAbbreviation":"Fam Pract","language":"eng","note":"PMID: 21239470","page":"323-328","source":"PubMed","title":"Diagnosing acute coronary syndrome in primary care: comparison of the physicians' risk estimation and a clinical decision rule","title-short":"Diagnosing acute coronary syndrome in primary care","volume":"28","author":[{"family":"Bruins Slot","given":"M. H. E."},{"family":"Rutten","given":"F. H."},{"family":"Heijden","given":"G. J. M. G.","non-dropping-particle":"van der"},{"family":"Geersing","given":"G. J."},{"family":"Glatz","given":"J. F. C."},{"family":"Hoes","given":"A. W."}],"issued":{"date-parts":[["2011",6]]}}}],"schema":""} 30,32,34 using the universal guidance on the diagnosis of MI ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"hJkhcPIa","properties":{"formattedCitation":"\\super 36\\nosupersub{}","plainCitation":"36","noteIndex":0},"citationItems":[{"id":415,"uris":[""],"uri":[""],"itemData":{"id":415,"type":"article-journal","container-title":"Circulation","DOI":"10.1161/CIRCULATIONAHA.107.187397","ISSN":"1524-4539","issue":"22","journalAbbreviation":"Circulation","language":"eng","note":"PMID: 17951284","page":"2634-2653","source":"PubMed","title":"Universal definition of myocardial infarction","volume":"116","author":[{"family":"Thygesen","given":"Kristian"},{"family":"Alpert","given":"Joseph S."},{"family":"White","given":"Harvey D."},{"literal":"Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction"},{"family":"Jaffe","given":"Allan S."},{"family":"Apple","given":"Fred S."},{"family":"Galvani","given":"Marcello"},{"family":"Katus","given":"Hugo A."},{"family":"Newby","given":"L. Kristin"},{"family":"Ravkilde","given":"Jan"},{"family":"Chaitman","given":"Bernard"},{"family":"Clemmensen","given":"Peter M."},{"family":"Dellborg","given":"Mikael"},{"family":"Hod","given":"Hanoch"},{"family":"Porela","given":"Pekka"},{"family":"Underwood","given":"Richard"},{"family":"Bax","given":"Jeroen J."},{"family":"Beller","given":"George A."},{"family":"Bonow","given":"Robert"},{"family":"Van der Wall","given":"Ernst E."},{"family":"Bassand","given":"Jean-Pierre"},{"family":"Wijns","given":"William"},{"family":"Ferguson","given":"T. Bruce"},{"family":"Steg","given":"Philippe G."},{"family":"Uretsky","given":"Barry F."},{"family":"Williams","given":"David O."},{"family":"Armstrong","given":"Paul W."},{"family":"Antman","given":"Elliott M."},{"family":"Fox","given":"Keith A."},{"family":"Hamm","given":"Christian W."},{"family":"Ohman","given":"E. Magnus"},{"family":"Simoons","given":"Maarten L."},{"family":"Poole-Wilson","given":"Philip A."},{"family":"Gurfinkel","given":"Enrique P."},{"family":"Lopez-Sendon","given":"José-Luis"},{"family":"Pais","given":"Prem"},{"family":"Mendis","given":"Shanti"},{"family":"Zhu","given":"Jun-Ren"},{"family":"Wallentin","given":"Lars C."},{"family":"Fernández-Avilés","given":"Francisco"},{"family":"Fox","given":"Kim M."},{"family":"Parkhomenko","given":"Alexander N."},{"family":"Priori","given":"Silvia G."},{"family":"Tendera","given":"Michal"},{"family":"Voipio-Pulkki","given":"Liisa-Maria"},{"family":"Vahanian","given":"Alec"},{"family":"Camm","given":"A. John"},{"family":"De Caterina","given":"Raffaele"},{"family":"Dean","given":"Veronica"},{"family":"Dickstein","given":"Kenneth"},{"family":"Filippatos","given":"Gerasimos"},{"family":"Funck-Brentano","given":"Christian"},{"family":"Hellemans","given":"Irene"},{"family":"Kristensen","given":"Steen Dalby"},{"family":"McGregor","given":"Keith"},{"family":"Sechtem","given":"Udo"},{"family":"Silber","given":"Sigmund"},{"family":"Tendera","given":"Michal"},{"family":"Widimsky","given":"Petr"},{"family":"Zamorano","given":"José Luis"},{"family":"Morais","given":"Joao"},{"family":"Brener","given":"Sorin"},{"family":"Harrington","given":"Robert"},{"family":"Morrow","given":"David"},{"family":"Lim","given":"Michael"},{"family":"Martinez-Rios","given":"Marco A."},{"family":"Steinhubl","given":"Steve"},{"family":"Levine","given":"Glen N."},{"family":"Gibler","given":"W. Brian"},{"family":"Goff","given":"David"},{"family":"Tubaro","given":"Marco"},{"family":"Dudek","given":"Darek"},{"family":"Al-Attar","given":"Nawwar"}],"issued":{"date-parts":[["2007",11,27]]}}}],"schema":""} 36, two other studies ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"7AnvvwfY","properties":{"formattedCitation":"\\super 16,35\\nosupersub{}","plainCitation":"16,35","noteIndex":0},"citationItems":[{"id":439,"uris":[""],"uri":[""],"itemData":{"id":439,"type":"article-journal","abstract":"BACKGROUND: The first study of the FamouS Triage project investigates the feasibility of ruling out a myocardial infarction in pre-hospital chest pain patients without electrocardiographic ST-segment elevation by using the modified HEART score at the patient's home, incorporating only a single highly sensitive troponin T measurement.\nMETHODS: A venous blood sample was drawn in the ambulance from 1127 consecutive chest pain patients for measurement of the pre-hospital highly sensitive troponin T levels, in order to establish a pre-hospital HEART score (i.e. the modified HEART score) and evaluate the possibility of triage at the patient's home. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) i.e. acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or death within 30 days after initial presentation.\nRESULTS: Two hundred and six patients (18%) developed a MACE during 30 days of follow-up. Thirty-six per cent of the patients ( n=403) had a low modified HEART score (0-3 points) and none of them developed a MACE during follow-up. Forty-four per cent of the patients ( n=494) had an intermediate modified HEART score (4-6 points) and 18% of them developed a MACE. Twenty per cent of the patients ( n=230) had a high modified HEART score (7-10 points) of which 52% developed a MACE during follow-up.\nCONCLUSION: It seems feasible to rule out a myocardial infarction at home in chest pain patients without ST-segment elevation by using the modified HEART score.\nTRIAL ID: NTR4205. Dutch Trial Register [ ]: trial number 4205.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872616687116","ISSN":"2048-8734","issue":"2","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 28084079","page":"102-110","source":"PubMed","title":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score","title-short":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage)","volume":"7","author":[{"family":"Ishak","given":"Maycel"},{"family":"Ali","given":"Danish"},{"family":"Fokkert","given":"Marion J."},{"family":"Slingerland","given":"Robbert J."},{"family":"Tolsma","given":"Rudolf T."},{"family":"Badings","given":"Erik"},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Eenennaam","given":"Fred","non-dropping-particle":"van"},{"family":"Mosterd","given":"Arend"},{"family":"Ten Berg","given":"Jurri?n M."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"}],"issued":{"date-parts":[["2018",3]]}}},{"id":435,"uris":[""],"uri":[""],"itemData":{"id":435,"type":"article-journal","abstract":"BACKGROUND:: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE).\nMETHODS:: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ? 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death.\nRESULTS:: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%).\nCONCLUSIONS:: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872618813846","ISSN":"2048-8734","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 30468395","page":"2048872618813846","source":"PubMed","title":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study","title-short":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome","author":[{"family":"Dongen","given":"Dominique N.","non-dropping-particle":"van"},{"family":"Tolsma","given":"Rudolf T."},{"family":"Fokkert","given":"Marion J."},{"family":"Badings","given":"Erik A."},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Slingerland","given":"Robbert J."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"},{"family":"Ottervanger","given":"Jan Paul"}],"issued":{"date-parts":[["2018",11,23]]}}}],"schema":""} 16,35 used the third universal definition of MI ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"kQe2AQ03","properties":{"formattedCitation":"\\super 37\\nosupersub{}","plainCitation":"37","noteIndex":0},"citationItems":[{"id":421,"uris":[""],"uri":[""],"itemData":{"id":421,"type":"article-journal","container-title":"Circulation","DOI":"10.1161/CIR.0b013e31826e1058","ISSN":"1524-4539","issue":"16","journalAbbreviation":"Circulation","language":"eng","note":"PMID: 22923432","page":"2020-2035","source":"PubMed","title":"Third universal definition of myocardial infarction","volume":"126","author":[{"family":"Thygesen","given":"Kristian"},{"family":"Alpert","given":"Joseph S."},{"family":"Jaffe","given":"Allan S."},{"family":"Simoons","given":"Maarten L."},{"family":"Chaitman","given":"Bernard R."},{"family":"White","given":"Harvey D."},{"literal":"Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction"},{"family":"Katus","given":"Hugo A."},{"family":"Lindahl","given":"Bertil"},{"family":"Morrow","given":"David A."},{"family":"Clemmensen","given":"Peter M."},{"family":"Johanson","given":"Per"},{"family":"Hod","given":"Hanoch"},{"family":"Underwood","given":"Richard"},{"family":"Bax","given":"Jeroen J."},{"family":"Bonow","given":"Robert O."},{"family":"Pinto","given":"Fausto"},{"family":"Gibbons","given":"Raymond J."},{"family":"Fox","given":"Keith A."},{"family":"Atar","given":"Dan"},{"family":"Newby","given":"L. Kristin"},{"family":"Galvani","given":"Marcello"},{"family":"Hamm","given":"Christian W."},{"family":"Uretsky","given":"Barry F."},{"family":"Steg","given":"Ph Gabriel"},{"family":"Wijns","given":"William"},{"family":"Bassand","given":"Jean-Pierre"},{"family":"Menasché","given":"Phillippe"},{"family":"Ravkilde","given":"Jan"},{"family":"Ohman","given":"E. Magnus"},{"family":"Antman","given":"Elliott M."},{"family":"Wallentin","given":"Lars C."},{"family":"Armstrong","given":"Paul W."},{"family":"Simoons","given":"Maarten L."},{"family":"Januzzi","given":"James L."},{"family":"Nieminen","given":"Markku S."},{"family":"Gheorghiade","given":"Mihai"},{"family":"Filippatos","given":"Gerasimos"},{"family":"Luepker","given":"Russell V."},{"family":"Fortmann","given":"Stephen P."},{"family":"Rosamond","given":"Wayne D."},{"family":"Levy","given":"Dan"},{"family":"Wood","given":"David"},{"family":"Smith","given":"Sidney C."},{"family":"Hu","given":"Dayi"},{"family":"Lopez-Sendon","given":"José-Luis"},{"family":"Robertson","given":"Rose Marie"},{"family":"Weaver","given":"Douglas"},{"family":"Tendera","given":"Michal"},{"family":"Bove","given":"Alfred A."},{"family":"Parkhomenko","given":"Alexander N."},{"family":"Vasilieva","given":"Elena J."},{"family":"Mendis","given":"Shanti"}],"issued":{"date-parts":[["2012",10,16]]}}}],"schema":""} 37, while the final three used a combination of ECG findings, biomarkers and history to diagnose ACS ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"MC0OLZOT","properties":{"formattedCitation":"\\super 20,31,33\\nosupersub{}","plainCitation":"20,31,33","noteIndex":0},"citationItems":[{"id":445,"uris":[""],"uri":[""],"itemData":{"id":445,"type":"article-journal","abstract":"BACKGROUND: Identifying ST-segment elevation myocardial infarctions (STEMIs) in the field can decrease door-to-balloon times. Paramedics may use a computer algorithm to help them interpret prehospital electrocariograms (ECGs). It is unknown how accurately the computer can identify STEMIs.\nOBJECTIVES: To Determine the sensitivity and specificity of prehospital ECGs in identifying patients with STEMI.\nMETHODS: Retrospective cross-sectional study of 200 prehospital ECGs acquired using Lifepak 12 monitors and transmitted by one of more than 20 emergency medical services (EMS) agencies to the emergency department (ED) of a Summa Akron City Hospital, a level 1 trauma center between January 1, 2007, and February 18, 2010. The ED sees more than 73,000 adult patients and treats 120 STEMIs annually. The laboratory performs 3,400 catheterizations annually. The first 100 patients with a diagnosis of STEMI and cardiac catheterization laboratory activation from the ED were analyzed. For comparison, a control group of 100 other ECGs from patients without a STEMI were randomly selected from our Medtronic database using a random-number generator. For patients with STEMI, an accurate computer interpretation was \"acute MI suspected.\" Other interpretations were counted as misses. Specificity and sensitivity were calculated with confidence intervals (CIs). The sample size was determined a priori for a 95% CI of ±10%.\nRESULTS: Zero control patients were incorrectly labeled \"acute MI suspected.\" The specificity was 100% (100/100; 95% CI 0.96-1.0), whereas the sensitivity was 58% (58/100; 95% CI 0.48-0.67). This would have resulted in 42 missed cardiac catheterization laboratory activations, but zero inappropriate activations. The most common incorrect interpretation of STEMI ECGs by the computer was \"data quality prohibits interpretation,\" followed by \"abnormal ECG unconfirmed.\"\nCONCLUSIONS: Prehospital computer interpretation is not sensitive for STEMI identification and should not be used as a single method for prehospital activation of the cardiac catheterizing laboratory. Because of its high specificity, it may serve as an adjunct to interpretation.","container-title":"Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors","DOI":"10.3109/10903127.2012.722176","ISSN":"1545-0066","issue":"2","journalAbbreviation":"Prehosp Emerg Care","language":"eng","note":"PMID: 23066910","page":"211-216","source":"PubMed","title":"Prehospital electrocardiographic computer identification of ST-segment elevation myocardial infarction","volume":"17","author":[{"family":"Bhalla","given":"Mary Colleen"},{"family":"Mencl","given":"Francis"},{"family":"Gist","given":"Mikki Amber"},{"family":"Wilber","given":"Scott"},{"family":"Zalewski","given":"Jon"}],"issued":{"date-parts":[["2013",6]]}}},{"id":437,"uris":[""],"uri":[""],"itemData":{"id":437,"type":"article-journal","abstract":"BACKGROUND: The purposes of this study were to create a new flow-chart of prehospital electrocardiography (ECG)-transmission, evaluate its predictive ability for ST-elevation myocardial infarction (STEMI) and shorten door-to-balloon time (DTBT).\nMETHOD AND RESULTS: The new transmission flow-chart was created using symptoms from previous medical records of STEMI patients. A total of 4090 consecutive patients transferred emergently to our hospital were divided into two groups: those in ambulances with an ECG-transmission device with the new flow-chart (ECGT-FC) and those transferred without an ECG-transmission device (non-ECGT) groups. A STEMI group comprising walk-in patients during the same period was used as a control group. The predictive ability of STEMI and the effectiveness of shortening the DTBT by the new flow-chart of ECG-transmission was evaluated. In the ECGT-FC group, the prevalence of STEMI in the ECG-transmission by the new flow-chart were significantly higher than in the non-ECG-transmission patients (6.71% vs. 0.19%; p<0.001). The sensitivity and specificity of the new ECG-transmission flow-chart were 83.3% and 88.1%, respectively. The median DTBT was significantly shortened (p=0.045) and the prevalence of DTBT<90min was significantly higher in the ECGT-FC group (p=0.018) than the other groups.\nCONCLUSION: The sensitivity and specificity of the new flow-chart for ECG-transmission were high. The new flow-chart combined with an ECG-transmission device could detect STEMI efficiently and shorten DTBT.","container-title":"Journal of Cardiology","DOI":"10.1016/j.jjcc.2018.03.011","ISSN":"1876-4738","issue":"4","journalAbbreviation":"J Cardiol","language":"eng","note":"PMID: 29804908","page":"335-342","source":"PubMed","title":"Predictive ability and efficacy for shortening door-to-balloon time of a new prehospital electrocardiogram-transmission flow chart in patients with ST-elevation myocardial infarction - Results of the CASSIOPEIA study","volume":"72","author":[{"family":"Sakai","given":"Toshiaki"},{"family":"Nishiyama","given":"Osamu"},{"family":"Onodera","given":"Masayuki"},{"family":"Matsuda","given":"Shigekatsu"},{"family":"Wakisawa","given":"Shinobu"},{"family":"Nakamura","given":"Motoyuki"},{"family":"Morino","given":"Yoshihiro"},{"family":"Itoh","given":"Tomonori"},{"literal":"CASSIOPEIA study group"}],"issued":{"date-parts":[["2018",10]]}}},{"id":478,"uris":[""],"uri":[""],"itemData":{"id":478,"type":"article-journal","abstract":"OBJECTIVE: To improve pre-hospital triage of patients with suspected acute cardiac disease.\nDESIGN: Prospective study. SUBJECTS. Patients with symptoms suggestive of acute cardiac pathology, who were seen by a general practitioner, for whom acute admission into hospital was requested, and in whom a pre-hospital electrocardiogram was recorded by the ambulance service.\nMETHODS: The study consisted of two phases. In the first phase, a decision rule was developed based on clinical characteristics and electrocardiographic findings in 1005 patients with suspected acute cardiac pathology. In the second phase, the decision rule was prospectively validated. Symptoms were recorded by a standardized questionnaire by the general practitioner and a computerized electrocardiogram was made by the ambulance nurses at the patient's home. Three electrocardiographic outcomes were available: 'normal electrocardiogram', 'possible myocardial infarction' or 'extensive myocardial infarction'. By use of the predictive model, the general practitioner could decide if hospitalization was necessary or not.\nMAIN OUTCOME MEASUREMENTS: Identification of patients at low (stable angina, atypical chest pain, other pathology) and high (myocardial infarction, unstable angina) probability of acute cardiac pathology.\nRESULTS: Among 977 patients with a complete pre-hospital evaluation in the validation phase of the study, the decision rule recommended 'no hospitalization' in 227 patients (23%). The general practitioner followed this advice in 44% of these patients. Although seven of them developed a non-Q wave myocardial infarction, no complications occurred in patients not admitted. In addition, the general practitioner did not hospitalize 19 (2%) of 750 patients for whom the decision rule recommended admission. Pre-hospital triage by the general practitioner resulted in a 12% (118 of 977 patients) reduction of the number of patients admitted to the Coronary Care Units.\nCONCLUSIONS: Pre-hospital triage by the general practitioner was facilitated using a standardized questionnaire and pre-hospital electrocardiography, and resulted in a reduction in the number of patients admitted to the Coronary Care Unit, and proved to be safe.","container-title":"European Heart Journal","ISSN":"0195-668X","issue":"1","journalAbbreviation":"Eur. Heart J.","language":"eng","note":"PMID: 8682136","page":"89-95","source":"PubMed","title":"Implementation of a pre-hospital decision rule in general practice. Triage of patients with suspected myocardial infarction","volume":"17","author":[{"family":"Grijseels","given":"E. W."},{"family":"Deckers","given":"J. W."},{"family":"Hoes","given":"A. W."},{"family":"Boersma","given":"E."},{"family":"Hartman","given":"J. A."},{"family":"Does","given":"E.","non-dropping-particle":"van der"},{"family":"Simoons","given":"M. L."}],"issued":{"date-parts":[["1996",1]]}}}],"schema":""} 20,31,33. The incidence of the ACS also was widely different between the studies, ranging from 0.02% to 50%. Statistical analysisThe results of the analysis of the outcomes, sensitivities, specificity, positive predictive value and negative predictive value of the studies are described in Table 2. The sensitivity between the studies varied from 100% to 58%, with specificity varying from 100% to 10%, positive predictive value between 100% and 7%, and negative predictive value between 100% and 30%. Table 3 shows that only the inclusion of patient history was found to have a significant impact on improving accuracy of sensitivity and negative predictive value of CDSS. DISCUSSIONThe utility of CDSS for ACS in pre-hospital settings is yet to be established. This systematic review of the literature, the first to be conducted on the topic, found considerable variations in the components of CDSS that were examined in existing studies. The extent of the heterogeneity precluded a formal meta-analysis, however, a comparison of which components were key in successful CDSS was performed. This review found that the use of the patient history component in CDSS remains highly important in diagnosis with significant improvement on the sensitivity (p = 0.002) and negative predictive value (p<0.001). These findings highlight the potential of CDSS that incorporate patient history in a ‘rule-out’ capacity for an ACS diagnosis. The significant impact of patient history in this review, may have been due to patient history being the most prevalent tool in CDSS with it being included in seven of the eight studies reviewed ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"rma7Jd56","properties":{"formattedCitation":"\\super 16,30\\uc0\\u8211{}35\\nosupersub{}","plainCitation":"16,30–35","noteIndex":0},"citationItems":[{"id":441,"uris":[""],"uri":[""],"itemData":{"id":441,"type":"article-journal","abstract":"BACKGROUND: To evaluate whether a computer-based decision support system could improve the allocation of patients with acute coronary syndrome (ACS) or a life-threatening condition (LTC). We hypothesised that a system of this kind would improve sensitivity without compromising specificity.\nMETHODS: A total of 2285 consecutive patients who dialed 112 due to chest pain were asked 10 specific questions and a prediction model was constructed based on the answers. We compared the sensitivity of the dispatchers' decisions with that of the model-based decision support model.\nRESULTS: A total of 2048 patients answered all 10 questions. Among the 235 patients with ACS, 194 were allocated the highest prioritisation by dispatchers (sensitivity 82.6%) and 41 patients were given a lower prioritisation (17.4% false negatives). The allocation suggested by the model used the highest prioritisation in 212 of the patients with ACS (sensitivity of 90.2%), while 23 patients were underprioritised (9.8% false negatives). The results were similar when the two systems were compared with regard to LTC and 30-day mortality. This indicates that computer-based decision support could be used either for increasing sensitivity or for saving resources. Three questions proved to be most important in terms of predicting ACS/LTC, [1] the intensity of pain, [2] the localisation of pain and [3] a history of ACS.\nCONCLUSION: Among patients with acute chest pain, computer-based decision support with a model based on a few fundamental questions could improve sensitivity and reduce the number of cases with the highest prioritisation without endangering the patients.","container-title":"International Journal of Cardiology","DOI":"10.1016/j.ijcard.2016.06.281","ISSN":"1874-1754","journalAbbreviation":"Int. J. Cardiol.","language":"eng","note":"PMID: 27393857","page":"734-738","source":"PubMed","title":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support? A cohort of patients with chest pain","title-short":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support?","volume":"220","author":[{"family":"Gellerstedt","given":"Martin"},{"family":"Rawshani","given":"Nina"},{"family":"Herlitz","given":"Johan"},{"family":"B?ng","given":"Angela"},{"family":"Gelang","given":"Carita"},{"family":"Andersson","given":"Jan-Otto"},{"family":"Larsson","given":"Anna"},{"family":"Rawshani","given":"Araz"}],"issued":{"date-parts":[["2016",10,1]]}}},{"id":220,"uris":[""],"uri":[""],"itemData":{"id":220,"type":"article-journal","abstract":"OBJECTIVE: ST-elevation myocardial infarction (STEMI) identification by emergency medicine services (EMS) leading to pre-hospital catheterization laboratory (CL) activation shortens ischemic time and improves outcomes. We examined the incremental value of addition of a screening clinical tool (CT), containing clinical information and a Zoll electrocardiogram (ECG)-resident STEMI identification program (ZI) to ZI alone.\nMETHODS: All EMS-performed and ZI-analyzed ECGs transmitted to a percutaneous coronary intervention hospital from October 2009 to January 2011 were reviewed for diagnostic accuracy. ZI performance was also compared to ECG interpretations by 2 experienced readers The CT was then retrospectively applied to determine the incremental benefit above the ZI alone.\nRESULTS: ST-elevation myocardial infarction was confirmed in 23 (7.5%) of 305 patients. ZI was positive in 37 (12.1%): sensitivity: 95.6% and specificity: 94.6%, positive predictive value (PPV), 59.5%, negative predictive value (NPV), 99.6%, and accuracy of 93.8%. Moderate agreement was observed among the readers and ZI. CT criteria for CL activation were met in 24 (7.8%): 20 (83.3%) were confirmed STEMIs: sensitivity: 86.9%, specificity: 98.5%, a PPV: 83.3%, and NPV: 98.6%, accuracy of 97.7%. CT + ZI increased PPV (P<0.05) and specificity (P<0.003) by reducing false positive STEMI identifications from 15 (4.9%) to 4 (1.3%).\nCONCLUSIONS: In an urban cohort of all EMS transmitted ECGs, ZI has high sensitivity and specificity for STEMI identification. Whereas the PPV was low, reflecting both low STEMI prevalence and presence of STEMI-mimics, the NPV was very high. These findings suggest that a simplified CT combined with computer STEMI interpretation can identify patients for pre-hospital CL activation. Confirmation of these results could improve the design of STEMI care systems.","container-title":"The American Journal of Emergency Medicine","DOI":"10.1016/j.ajem.2013.04.013","ISSN":"1532-8171","issue":"7","journalAbbreviation":"Am J Emerg Med","language":"eng","note":"PMID: 23706572","page":"1098-1102","source":"PubMed","title":"An algorithm for identification of ST-elevation myocardial infarction patients by emergency medicine services","volume":"31","author":[{"family":"Wilson","given":"Ryan E."},{"family":"Kado","given":"Herman S."},{"family":"Percy","given":"Robert F."},{"family":"Butterfield","given":"Ryan C."},{"family":"Sabato","given":"Joseph"},{"family":"Strom","given":"Joel A."},{"family":"Box","given":"Lyndon C."}],"issued":{"date-parts":[["2013",7]]}}},{"id":439,"uris":[""],"uri":[""],"itemData":{"id":439,"type":"article-journal","abstract":"BACKGROUND: The first study of the FamouS Triage project investigates the feasibility of ruling out a myocardial infarction in pre-hospital chest pain patients without electrocardiographic ST-segment elevation by using the modified HEART score at the patient's home, incorporating only a single highly sensitive troponin T measurement.\nMETHODS: A venous blood sample was drawn in the ambulance from 1127 consecutive chest pain patients for measurement of the pre-hospital highly sensitive troponin T levels, in order to establish a pre-hospital HEART score (i.e. the modified HEART score) and evaluate the possibility of triage at the patient's home. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) i.e. acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or death within 30 days after initial presentation.\nRESULTS: Two hundred and six patients (18%) developed a MACE during 30 days of follow-up. Thirty-six per cent of the patients ( n=403) had a low modified HEART score (0-3 points) and none of them developed a MACE during follow-up. Forty-four per cent of the patients ( n=494) had an intermediate modified HEART score (4-6 points) and 18% of them developed a MACE. Twenty per cent of the patients ( n=230) had a high modified HEART score (7-10 points) of which 52% developed a MACE during follow-up.\nCONCLUSION: It seems feasible to rule out a myocardial infarction at home in chest pain patients without ST-segment elevation by using the modified HEART score.\nTRIAL ID: NTR4205. Dutch Trial Register [ ]: trial number 4205.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872616687116","ISSN":"2048-8734","issue":"2","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 28084079","page":"102-110","source":"PubMed","title":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score","title-short":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage)","volume":"7","author":[{"family":"Ishak","given":"Maycel"},{"family":"Ali","given":"Danish"},{"family":"Fokkert","given":"Marion J."},{"family":"Slingerland","given":"Robbert J."},{"family":"Tolsma","given":"Rudolf T."},{"family":"Badings","given":"Erik"},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Eenennaam","given":"Fred","non-dropping-particle":"van"},{"family":"Mosterd","given":"Arend"},{"family":"Ten Berg","given":"Jurri?n M."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"}],"issued":{"date-parts":[["2018",3]]}}},{"id":437,"uris":[""],"uri":[""],"itemData":{"id":437,"type":"article-journal","abstract":"BACKGROUND: The purposes of this study were to create a new flow-chart of prehospital electrocardiography (ECG)-transmission, evaluate its predictive ability for ST-elevation myocardial infarction (STEMI) and shorten door-to-balloon time (DTBT).\nMETHOD AND RESULTS: The new transmission flow-chart was created using symptoms from previous medical records of STEMI patients. A total of 4090 consecutive patients transferred emergently to our hospital were divided into two groups: those in ambulances with an ECG-transmission device with the new flow-chart (ECGT-FC) and those transferred without an ECG-transmission device (non-ECGT) groups. A STEMI group comprising walk-in patients during the same period was used as a control group. The predictive ability of STEMI and the effectiveness of shortening the DTBT by the new flow-chart of ECG-transmission was evaluated. In the ECGT-FC group, the prevalence of STEMI in the ECG-transmission by the new flow-chart were significantly higher than in the non-ECG-transmission patients (6.71% vs. 0.19%; p<0.001). The sensitivity and specificity of the new ECG-transmission flow-chart were 83.3% and 88.1%, respectively. The median DTBT was significantly shortened (p=0.045) and the prevalence of DTBT<90min was significantly higher in the ECGT-FC group (p=0.018) than the other groups.\nCONCLUSION: The sensitivity and specificity of the new flow-chart for ECG-transmission were high. The new flow-chart combined with an ECG-transmission device could detect STEMI efficiently and shorten DTBT.","container-title":"Journal of Cardiology","DOI":"10.1016/j.jjcc.2018.03.011","ISSN":"1876-4738","issue":"4","journalAbbreviation":"J Cardiol","language":"eng","note":"PMID: 29804908","page":"335-342","source":"PubMed","title":"Predictive ability and efficacy for shortening door-to-balloon time of a new prehospital electrocardiogram-transmission flow chart in patients with ST-elevation myocardial infarction - Results of the CASSIOPEIA study","volume":"72","author":[{"family":"Sakai","given":"Toshiaki"},{"family":"Nishiyama","given":"Osamu"},{"family":"Onodera","given":"Masayuki"},{"family":"Matsuda","given":"Shigekatsu"},{"family":"Wakisawa","given":"Shinobu"},{"family":"Nakamura","given":"Motoyuki"},{"family":"Morino","given":"Yoshihiro"},{"family":"Itoh","given":"Tomonori"},{"literal":"CASSIOPEIA study group"}],"issued":{"date-parts":[["2018",10]]}}},{"id":447,"uris":[""],"uri":[""],"itemData":{"id":447,"type":"article-journal","abstract":"BACKGROUND: Diagnosing acute coronary syndrome (ACS) in a primary care setting poses a diagnostic dilemma for physicians.\nOBJECTIVE: We directly compared the diagnostic accuracy of a clinical decision rule (CDR) based on history taking and physical examination in suspected ACS with the risk estimates of the attending GP.\nMETHODS: In a prospective multicenter study, patients suspected of ACS were included by the GP. GPs were asked to estimate the probability (0%-100%) of the presence of ACS. GPs collected patient data, but they were not aware of the CDR and did not score the patient accordingly.\nRESULTS: Two hundred and ninety-eight patients were included (52% female, mean age 66 years, 22% ACS). The area under the receiver operating characteristic (ROC) curve (AUC) was 0.75 [95% confidence interval (CI) 0.68-0.82] for the GP risk estimate and 0.66 (95% CI 0.58-0.73) for the CDR. There was an agreement between the risk estimation of the GP and a CDR in 51% and the prevalence of ACS in predefined low-, intermediate- and high-risk groups was similar for the GP and CDR estimates. In the low-risk group, according to the GP, four patients (8.2%) suffered an ACS. These four patients were all identified by the decision rule as high risk.\nCONCLUSIONS: The GP classified patients as ACS or no ACS more adequately than the CDR, judged by the AUC. However, the use of a CDR in patients that are considered at low risk for ACS by the GP could reduce the amount of missed myocardial infarctions.","container-title":"Family Practice","DOI":"10.1093/fampra/cmq116","ISSN":"1460-2229","issue":"3","journalAbbreviation":"Fam Pract","language":"eng","note":"PMID: 21239470","page":"323-328","source":"PubMed","title":"Diagnosing acute coronary syndrome in primary care: comparison of the physicians' risk estimation and a clinical decision rule","title-short":"Diagnosing acute coronary syndrome in primary care","volume":"28","author":[{"family":"Bruins Slot","given":"M. H. E."},{"family":"Rutten","given":"F. H."},{"family":"Heijden","given":"G. J. M. G.","non-dropping-particle":"van der"},{"family":"Geersing","given":"G. J."},{"family":"Glatz","given":"J. F. C."},{"family":"Hoes","given":"A. W."}],"issued":{"date-parts":[["2011",6]]}}},{"id":435,"uris":[""],"uri":[""],"itemData":{"id":435,"type":"article-journal","abstract":"BACKGROUND:: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE).\nMETHODS:: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ? 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death.\nRESULTS:: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%).\nCONCLUSIONS:: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872618813846","ISSN":"2048-8734","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 30468395","page":"2048872618813846","source":"PubMed","title":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study","title-short":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome","author":[{"family":"Dongen","given":"Dominique N.","non-dropping-particle":"van"},{"family":"Tolsma","given":"Rudolf T."},{"family":"Fokkert","given":"Marion J."},{"family":"Badings","given":"Erik A."},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Slingerland","given":"Robbert J."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"},{"family":"Ottervanger","given":"Jan Paul"}],"issued":{"date-parts":[["2018",11,23]]}}},{"id":478,"uris":[""],"uri":[""],"itemData":{"id":478,"type":"article-journal","abstract":"OBJECTIVE: To improve pre-hospital triage of patients with suspected acute cardiac disease.\nDESIGN: Prospective study. SUBJECTS. Patients with symptoms suggestive of acute cardiac pathology, who were seen by a general practitioner, for whom acute admission into hospital was requested, and in whom a pre-hospital electrocardiogram was recorded by the ambulance service.\nMETHODS: The study consisted of two phases. In the first phase, a decision rule was developed based on clinical characteristics and electrocardiographic findings in 1005 patients with suspected acute cardiac pathology. In the second phase, the decision rule was prospectively validated. Symptoms were recorded by a standardized questionnaire by the general practitioner and a computerized electrocardiogram was made by the ambulance nurses at the patient's home. Three electrocardiographic outcomes were available: 'normal electrocardiogram', 'possible myocardial infarction' or 'extensive myocardial infarction'. By use of the predictive model, the general practitioner could decide if hospitalization was necessary or not.\nMAIN OUTCOME MEASUREMENTS: Identification of patients at low (stable angina, atypical chest pain, other pathology) and high (myocardial infarction, unstable angina) probability of acute cardiac pathology.\nRESULTS: Among 977 patients with a complete pre-hospital evaluation in the validation phase of the study, the decision rule recommended 'no hospitalization' in 227 patients (23%). The general practitioner followed this advice in 44% of these patients. Although seven of them developed a non-Q wave myocardial infarction, no complications occurred in patients not admitted. In addition, the general practitioner did not hospitalize 19 (2%) of 750 patients for whom the decision rule recommended admission. Pre-hospital triage by the general practitioner resulted in a 12% (118 of 977 patients) reduction of the number of patients admitted to the Coronary Care Units.\nCONCLUSIONS: Pre-hospital triage by the general practitioner was facilitated using a standardized questionnaire and pre-hospital electrocardiography, and resulted in a reduction in the number of patients admitted to the Coronary Care Unit, and proved to be safe.","container-title":"European Heart Journal","ISSN":"0195-668X","issue":"1","journalAbbreviation":"Eur. Heart J.","language":"eng","note":"PMID: 8682136","page":"89-95","source":"PubMed","title":"Implementation of a pre-hospital decision rule in general practice. Triage of patients with suspected myocardial infarction","volume":"17","author":[{"family":"Grijseels","given":"E. W."},{"family":"Deckers","given":"J. W."},{"family":"Hoes","given":"A. W."},{"family":"Boersma","given":"E."},{"family":"Hartman","given":"J. A."},{"family":"Does","given":"E.","non-dropping-particle":"van der"},{"family":"Simoons","given":"M. L."}],"issued":{"date-parts":[["1996",1]]}}}],"schema":""} 16,30–35. In comparison, pre-hospital ECG was used in six of the eight studies ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"I61Z2KEE","properties":{"formattedCitation":"\\super 16,20,31,33\\uc0\\u8211{}35\\nosupersub{}","plainCitation":"16,20,31,33–35","noteIndex":0},"citationItems":[{"id":220,"uris":[""],"uri":[""],"itemData":{"id":220,"type":"article-journal","abstract":"OBJECTIVE: ST-elevation myocardial infarction (STEMI) identification by emergency medicine services (EMS) leading to pre-hospital catheterization laboratory (CL) activation shortens ischemic time and improves outcomes. We examined the incremental value of addition of a screening clinical tool (CT), containing clinical information and a Zoll electrocardiogram (ECG)-resident STEMI identification program (ZI) to ZI alone.\nMETHODS: All EMS-performed and ZI-analyzed ECGs transmitted to a percutaneous coronary intervention hospital from October 2009 to January 2011 were reviewed for diagnostic accuracy. ZI performance was also compared to ECG interpretations by 2 experienced readers The CT was then retrospectively applied to determine the incremental benefit above the ZI alone.\nRESULTS: ST-elevation myocardial infarction was confirmed in 23 (7.5%) of 305 patients. ZI was positive in 37 (12.1%): sensitivity: 95.6% and specificity: 94.6%, positive predictive value (PPV), 59.5%, negative predictive value (NPV), 99.6%, and accuracy of 93.8%. Moderate agreement was observed among the readers and ZI. CT criteria for CL activation were met in 24 (7.8%): 20 (83.3%) were confirmed STEMIs: sensitivity: 86.9%, specificity: 98.5%, a PPV: 83.3%, and NPV: 98.6%, accuracy of 97.7%. CT + ZI increased PPV (P<0.05) and specificity (P<0.003) by reducing false positive STEMI identifications from 15 (4.9%) to 4 (1.3%).\nCONCLUSIONS: In an urban cohort of all EMS transmitted ECGs, ZI has high sensitivity and specificity for STEMI identification. Whereas the PPV was low, reflecting both low STEMI prevalence and presence of STEMI-mimics, the NPV was very high. These findings suggest that a simplified CT combined with computer STEMI interpretation can identify patients for pre-hospital CL activation. Confirmation of these results could improve the design of STEMI care systems.","container-title":"The American Journal of Emergency Medicine","DOI":"10.1016/j.ajem.2013.04.013","ISSN":"1532-8171","issue":"7","journalAbbreviation":"Am J Emerg Med","language":"eng","note":"PMID: 23706572","page":"1098-1102","source":"PubMed","title":"An algorithm for identification of ST-elevation myocardial infarction patients by emergency medicine services","volume":"31","author":[{"family":"Wilson","given":"Ryan E."},{"family":"Kado","given":"Herman S."},{"family":"Percy","given":"Robert F."},{"family":"Butterfield","given":"Ryan C."},{"family":"Sabato","given":"Joseph"},{"family":"Strom","given":"Joel A."},{"family":"Box","given":"Lyndon C."}],"issued":{"date-parts":[["2013",7]]}}},{"id":445,"uris":[""],"uri":[""],"itemData":{"id":445,"type":"article-journal","abstract":"BACKGROUND: Identifying ST-segment elevation myocardial infarctions (STEMIs) in the field can decrease door-to-balloon times. Paramedics may use a computer algorithm to help them interpret prehospital electrocariograms (ECGs). It is unknown how accurately the computer can identify STEMIs.\nOBJECTIVES: To Determine the sensitivity and specificity of prehospital ECGs in identifying patients with STEMI.\nMETHODS: Retrospective cross-sectional study of 200 prehospital ECGs acquired using Lifepak 12 monitors and transmitted by one of more than 20 emergency medical services (EMS) agencies to the emergency department (ED) of a Summa Akron City Hospital, a level 1 trauma center between January 1, 2007, and February 18, 2010. The ED sees more than 73,000 adult patients and treats 120 STEMIs annually. The laboratory performs 3,400 catheterizations annually. The first 100 patients with a diagnosis of STEMI and cardiac catheterization laboratory activation from the ED were analyzed. For comparison, a control group of 100 other ECGs from patients without a STEMI were randomly selected from our Medtronic database using a random-number generator. For patients with STEMI, an accurate computer interpretation was \"acute MI suspected.\" Other interpretations were counted as misses. Specificity and sensitivity were calculated with confidence intervals (CIs). The sample size was determined a priori for a 95% CI of ±10%.\nRESULTS: Zero control patients were incorrectly labeled \"acute MI suspected.\" The specificity was 100% (100/100; 95% CI 0.96-1.0), whereas the sensitivity was 58% (58/100; 95% CI 0.48-0.67). This would have resulted in 42 missed cardiac catheterization laboratory activations, but zero inappropriate activations. The most common incorrect interpretation of STEMI ECGs by the computer was \"data quality prohibits interpretation,\" followed by \"abnormal ECG unconfirmed.\"\nCONCLUSIONS: Prehospital computer interpretation is not sensitive for STEMI identification and should not be used as a single method for prehospital activation of the cardiac catheterizing laboratory. Because of its high specificity, it may serve as an adjunct to interpretation.","container-title":"Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors","DOI":"10.3109/10903127.2012.722176","ISSN":"1545-0066","issue":"2","journalAbbreviation":"Prehosp Emerg Care","language":"eng","note":"PMID: 23066910","page":"211-216","source":"PubMed","title":"Prehospital electrocardiographic computer identification of ST-segment elevation myocardial infarction","volume":"17","author":[{"family":"Bhalla","given":"Mary Colleen"},{"family":"Mencl","given":"Francis"},{"family":"Gist","given":"Mikki Amber"},{"family":"Wilber","given":"Scott"},{"family":"Zalewski","given":"Jon"}],"issued":{"date-parts":[["2013",6]]}}},{"id":439,"uris":[""],"uri":[""],"itemData":{"id":439,"type":"article-journal","abstract":"BACKGROUND: The first study of the FamouS Triage project investigates the feasibility of ruling out a myocardial infarction in pre-hospital chest pain patients without electrocardiographic ST-segment elevation by using the modified HEART score at the patient's home, incorporating only a single highly sensitive troponin T measurement.\nMETHODS: A venous blood sample was drawn in the ambulance from 1127 consecutive chest pain patients for measurement of the pre-hospital highly sensitive troponin T levels, in order to establish a pre-hospital HEART score (i.e. the modified HEART score) and evaluate the possibility of triage at the patient's home. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) i.e. acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or death within 30 days after initial presentation.\nRESULTS: Two hundred and six patients (18%) developed a MACE during 30 days of follow-up. Thirty-six per cent of the patients ( n=403) had a low modified HEART score (0-3 points) and none of them developed a MACE during follow-up. Forty-four per cent of the patients ( n=494) had an intermediate modified HEART score (4-6 points) and 18% of them developed a MACE. Twenty per cent of the patients ( n=230) had a high modified HEART score (7-10 points) of which 52% developed a MACE during follow-up.\nCONCLUSION: It seems feasible to rule out a myocardial infarction at home in chest pain patients without ST-segment elevation by using the modified HEART score.\nTRIAL ID: NTR4205. Dutch Trial Register [ ]: trial number 4205.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872616687116","ISSN":"2048-8734","issue":"2","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 28084079","page":"102-110","source":"PubMed","title":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score","title-short":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage)","volume":"7","author":[{"family":"Ishak","given":"Maycel"},{"family":"Ali","given":"Danish"},{"family":"Fokkert","given":"Marion J."},{"family":"Slingerland","given":"Robbert J."},{"family":"Tolsma","given":"Rudolf T."},{"family":"Badings","given":"Erik"},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Eenennaam","given":"Fred","non-dropping-particle":"van"},{"family":"Mosterd","given":"Arend"},{"family":"Ten Berg","given":"Jurri?n M."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"}],"issued":{"date-parts":[["2018",3]]}}},{"id":437,"uris":[""],"uri":[""],"itemData":{"id":437,"type":"article-journal","abstract":"BACKGROUND: The purposes of this study were to create a new flow-chart of prehospital electrocardiography (ECG)-transmission, evaluate its predictive ability for ST-elevation myocardial infarction (STEMI) and shorten door-to-balloon time (DTBT).\nMETHOD AND RESULTS: The new transmission flow-chart was created using symptoms from previous medical records of STEMI patients. A total of 4090 consecutive patients transferred emergently to our hospital were divided into two groups: those in ambulances with an ECG-transmission device with the new flow-chart (ECGT-FC) and those transferred without an ECG-transmission device (non-ECGT) groups. A STEMI group comprising walk-in patients during the same period was used as a control group. The predictive ability of STEMI and the effectiveness of shortening the DTBT by the new flow-chart of ECG-transmission was evaluated. In the ECGT-FC group, the prevalence of STEMI in the ECG-transmission by the new flow-chart were significantly higher than in the non-ECG-transmission patients (6.71% vs. 0.19%; p<0.001). The sensitivity and specificity of the new ECG-transmission flow-chart were 83.3% and 88.1%, respectively. The median DTBT was significantly shortened (p=0.045) and the prevalence of DTBT<90min was significantly higher in the ECGT-FC group (p=0.018) than the other groups.\nCONCLUSION: The sensitivity and specificity of the new flow-chart for ECG-transmission were high. The new flow-chart combined with an ECG-transmission device could detect STEMI efficiently and shorten DTBT.","container-title":"Journal of Cardiology","DOI":"10.1016/j.jjcc.2018.03.011","ISSN":"1876-4738","issue":"4","journalAbbreviation":"J Cardiol","language":"eng","note":"PMID: 29804908","page":"335-342","source":"PubMed","title":"Predictive ability and efficacy for shortening door-to-balloon time of a new prehospital electrocardiogram-transmission flow chart in patients with ST-elevation myocardial infarction - Results of the CASSIOPEIA study","volume":"72","author":[{"family":"Sakai","given":"Toshiaki"},{"family":"Nishiyama","given":"Osamu"},{"family":"Onodera","given":"Masayuki"},{"family":"Matsuda","given":"Shigekatsu"},{"family":"Wakisawa","given":"Shinobu"},{"family":"Nakamura","given":"Motoyuki"},{"family":"Morino","given":"Yoshihiro"},{"family":"Itoh","given":"Tomonori"},{"literal":"CASSIOPEIA study group"}],"issued":{"date-parts":[["2018",10]]}}},{"id":435,"uris":[""],"uri":[""],"itemData":{"id":435,"type":"article-journal","abstract":"BACKGROUND:: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE).\nMETHODS:: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ? 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death.\nRESULTS:: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%).\nCONCLUSIONS:: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872618813846","ISSN":"2048-8734","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 30468395","page":"2048872618813846","source":"PubMed","title":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study","title-short":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome","author":[{"family":"Dongen","given":"Dominique N.","non-dropping-particle":"van"},{"family":"Tolsma","given":"Rudolf T."},{"family":"Fokkert","given":"Marion J."},{"family":"Badings","given":"Erik A."},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Slingerland","given":"Robbert J."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"},{"family":"Ottervanger","given":"Jan Paul"}],"issued":{"date-parts":[["2018",11,23]]}}},{"id":478,"uris":[""],"uri":[""],"itemData":{"id":478,"type":"article-journal","abstract":"OBJECTIVE: To improve pre-hospital triage of patients with suspected acute cardiac disease.\nDESIGN: Prospective study. SUBJECTS. Patients with symptoms suggestive of acute cardiac pathology, who were seen by a general practitioner, for whom acute admission into hospital was requested, and in whom a pre-hospital electrocardiogram was recorded by the ambulance service.\nMETHODS: The study consisted of two phases. In the first phase, a decision rule was developed based on clinical characteristics and electrocardiographic findings in 1005 patients with suspected acute cardiac pathology. In the second phase, the decision rule was prospectively validated. Symptoms were recorded by a standardized questionnaire by the general practitioner and a computerized electrocardiogram was made by the ambulance nurses at the patient's home. Three electrocardiographic outcomes were available: 'normal electrocardiogram', 'possible myocardial infarction' or 'extensive myocardial infarction'. By use of the predictive model, the general practitioner could decide if hospitalization was necessary or not.\nMAIN OUTCOME MEASUREMENTS: Identification of patients at low (stable angina, atypical chest pain, other pathology) and high (myocardial infarction, unstable angina) probability of acute cardiac pathology.\nRESULTS: Among 977 patients with a complete pre-hospital evaluation in the validation phase of the study, the decision rule recommended 'no hospitalization' in 227 patients (23%). The general practitioner followed this advice in 44% of these patients. Although seven of them developed a non-Q wave myocardial infarction, no complications occurred in patients not admitted. In addition, the general practitioner did not hospitalize 19 (2%) of 750 patients for whom the decision rule recommended admission. Pre-hospital triage by the general practitioner resulted in a 12% (118 of 977 patients) reduction of the number of patients admitted to the Coronary Care Units.\nCONCLUSIONS: Pre-hospital triage by the general practitioner was facilitated using a standardized questionnaire and pre-hospital electrocardiography, and resulted in a reduction in the number of patients admitted to the Coronary Care Unit, and proved to be safe.","container-title":"European Heart Journal","ISSN":"0195-668X","issue":"1","journalAbbreviation":"Eur. Heart J.","language":"eng","note":"PMID: 8682136","page":"89-95","source":"PubMed","title":"Implementation of a pre-hospital decision rule in general practice. Triage of patients with suspected myocardial infarction","volume":"17","author":[{"family":"Grijseels","given":"E. W."},{"family":"Deckers","given":"J. W."},{"family":"Hoes","given":"A. W."},{"family":"Boersma","given":"E."},{"family":"Hartman","given":"J. A."},{"family":"Does","given":"E.","non-dropping-particle":"van der"},{"family":"Simoons","given":"M. L."}],"issued":{"date-parts":[["1996",1]]}}}],"schema":""} 16,20,31,33–35, vital signs and examinations were used in five studies ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"fLOhr0wc","properties":{"formattedCitation":"\\super 16,31\\uc0\\u8211{}33,35\\nosupersub{}","plainCitation":"16,31–33,35","noteIndex":0},"citationItems":[{"id":439,"uris":[""],"uri":[""],"itemData":{"id":439,"type":"article-journal","abstract":"BACKGROUND: The first study of the FamouS Triage project investigates the feasibility of ruling out a myocardial infarction in pre-hospital chest pain patients without electrocardiographic ST-segment elevation by using the modified HEART score at the patient's home, incorporating only a single highly sensitive troponin T measurement.\nMETHODS: A venous blood sample was drawn in the ambulance from 1127 consecutive chest pain patients for measurement of the pre-hospital highly sensitive troponin T levels, in order to establish a pre-hospital HEART score (i.e. the modified HEART score) and evaluate the possibility of triage at the patient's home. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) i.e. acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or death within 30 days after initial presentation.\nRESULTS: Two hundred and six patients (18%) developed a MACE during 30 days of follow-up. Thirty-six per cent of the patients ( n=403) had a low modified HEART score (0-3 points) and none of them developed a MACE during follow-up. Forty-four per cent of the patients ( n=494) had an intermediate modified HEART score (4-6 points) and 18% of them developed a MACE. Twenty per cent of the patients ( n=230) had a high modified HEART score (7-10 points) of which 52% developed a MACE during follow-up.\nCONCLUSION: It seems feasible to rule out a myocardial infarction at home in chest pain patients without ST-segment elevation by using the modified HEART score.\nTRIAL ID: NTR4205. Dutch Trial Register [ ]: trial number 4205.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872616687116","ISSN":"2048-8734","issue":"2","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 28084079","page":"102-110","source":"PubMed","title":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score","title-short":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage)","volume":"7","author":[{"family":"Ishak","given":"Maycel"},{"family":"Ali","given":"Danish"},{"family":"Fokkert","given":"Marion J."},{"family":"Slingerland","given":"Robbert J."},{"family":"Tolsma","given":"Rudolf T."},{"family":"Badings","given":"Erik"},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Eenennaam","given":"Fred","non-dropping-particle":"van"},{"family":"Mosterd","given":"Arend"},{"family":"Ten Berg","given":"Jurri?n M."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"}],"issued":{"date-parts":[["2018",3]]}}},{"id":437,"uris":[""],"uri":[""],"itemData":{"id":437,"type":"article-journal","abstract":"BACKGROUND: The purposes of this study were to create a new flow-chart of prehospital electrocardiography (ECG)-transmission, evaluate its predictive ability for ST-elevation myocardial infarction (STEMI) and shorten door-to-balloon time (DTBT).\nMETHOD AND RESULTS: The new transmission flow-chart was created using symptoms from previous medical records of STEMI patients. A total of 4090 consecutive patients transferred emergently to our hospital were divided into two groups: those in ambulances with an ECG-transmission device with the new flow-chart (ECGT-FC) and those transferred without an ECG-transmission device (non-ECGT) groups. A STEMI group comprising walk-in patients during the same period was used as a control group. The predictive ability of STEMI and the effectiveness of shortening the DTBT by the new flow-chart of ECG-transmission was evaluated. In the ECGT-FC group, the prevalence of STEMI in the ECG-transmission by the new flow-chart were significantly higher than in the non-ECG-transmission patients (6.71% vs. 0.19%; p<0.001). The sensitivity and specificity of the new ECG-transmission flow-chart were 83.3% and 88.1%, respectively. The median DTBT was significantly shortened (p=0.045) and the prevalence of DTBT<90min was significantly higher in the ECGT-FC group (p=0.018) than the other groups.\nCONCLUSION: The sensitivity and specificity of the new flow-chart for ECG-transmission were high. The new flow-chart combined with an ECG-transmission device could detect STEMI efficiently and shorten DTBT.","container-title":"Journal of Cardiology","DOI":"10.1016/j.jjcc.2018.03.011","ISSN":"1876-4738","issue":"4","journalAbbreviation":"J Cardiol","language":"eng","note":"PMID: 29804908","page":"335-342","source":"PubMed","title":"Predictive ability and efficacy for shortening door-to-balloon time of a new prehospital electrocardiogram-transmission flow chart in patients with ST-elevation myocardial infarction - Results of the CASSIOPEIA study","volume":"72","author":[{"family":"Sakai","given":"Toshiaki"},{"family":"Nishiyama","given":"Osamu"},{"family":"Onodera","given":"Masayuki"},{"family":"Matsuda","given":"Shigekatsu"},{"family":"Wakisawa","given":"Shinobu"},{"family":"Nakamura","given":"Motoyuki"},{"family":"Morino","given":"Yoshihiro"},{"family":"Itoh","given":"Tomonori"},{"literal":"CASSIOPEIA study group"}],"issued":{"date-parts":[["2018",10]]}}},{"id":447,"uris":[""],"uri":[""],"itemData":{"id":447,"type":"article-journal","abstract":"BACKGROUND: Diagnosing acute coronary syndrome (ACS) in a primary care setting poses a diagnostic dilemma for physicians.\nOBJECTIVE: We directly compared the diagnostic accuracy of a clinical decision rule (CDR) based on history taking and physical examination in suspected ACS with the risk estimates of the attending GP.\nMETHODS: In a prospective multicenter study, patients suspected of ACS were included by the GP. GPs were asked to estimate the probability (0%-100%) of the presence of ACS. GPs collected patient data, but they were not aware of the CDR and did not score the patient accordingly.\nRESULTS: Two hundred and ninety-eight patients were included (52% female, mean age 66 years, 22% ACS). The area under the receiver operating characteristic (ROC) curve (AUC) was 0.75 [95% confidence interval (CI) 0.68-0.82] for the GP risk estimate and 0.66 (95% CI 0.58-0.73) for the CDR. There was an agreement between the risk estimation of the GP and a CDR in 51% and the prevalence of ACS in predefined low-, intermediate- and high-risk groups was similar for the GP and CDR estimates. In the low-risk group, according to the GP, four patients (8.2%) suffered an ACS. These four patients were all identified by the decision rule as high risk.\nCONCLUSIONS: The GP classified patients as ACS or no ACS more adequately than the CDR, judged by the AUC. However, the use of a CDR in patients that are considered at low risk for ACS by the GP could reduce the amount of missed myocardial infarctions.","container-title":"Family Practice","DOI":"10.1093/fampra/cmq116","ISSN":"1460-2229","issue":"3","journalAbbreviation":"Fam Pract","language":"eng","note":"PMID: 21239470","page":"323-328","source":"PubMed","title":"Diagnosing acute coronary syndrome in primary care: comparison of the physicians' risk estimation and a clinical decision rule","title-short":"Diagnosing acute coronary syndrome in primary care","volume":"28","author":[{"family":"Bruins Slot","given":"M. H. E."},{"family":"Rutten","given":"F. H."},{"family":"Heijden","given":"G. J. M. G.","non-dropping-particle":"van der"},{"family":"Geersing","given":"G. J."},{"family":"Glatz","given":"J. F. C."},{"family":"Hoes","given":"A. W."}],"issued":{"date-parts":[["2011",6]]}}},{"id":435,"uris":[""],"uri":[""],"itemData":{"id":435,"type":"article-journal","abstract":"BACKGROUND:: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE).\nMETHODS:: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ? 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death.\nRESULTS:: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%).\nCONCLUSIONS:: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872618813846","ISSN":"2048-8734","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 30468395","page":"2048872618813846","source":"PubMed","title":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study","title-short":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome","author":[{"family":"Dongen","given":"Dominique N.","non-dropping-particle":"van"},{"family":"Tolsma","given":"Rudolf T."},{"family":"Fokkert","given":"Marion J."},{"family":"Badings","given":"Erik A."},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Slingerland","given":"Robbert J."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"},{"family":"Ottervanger","given":"Jan Paul"}],"issued":{"date-parts":[["2018",11,23]]}}},{"id":478,"uris":[""],"uri":[""],"itemData":{"id":478,"type":"article-journal","abstract":"OBJECTIVE: To improve pre-hospital triage of patients with suspected acute cardiac disease.\nDESIGN: Prospective study. SUBJECTS. Patients with symptoms suggestive of acute cardiac pathology, who were seen by a general practitioner, for whom acute admission into hospital was requested, and in whom a pre-hospital electrocardiogram was recorded by the ambulance service.\nMETHODS: The study consisted of two phases. In the first phase, a decision rule was developed based on clinical characteristics and electrocardiographic findings in 1005 patients with suspected acute cardiac pathology. In the second phase, the decision rule was prospectively validated. Symptoms were recorded by a standardized questionnaire by the general practitioner and a computerized electrocardiogram was made by the ambulance nurses at the patient's home. Three electrocardiographic outcomes were available: 'normal electrocardiogram', 'possible myocardial infarction' or 'extensive myocardial infarction'. By use of the predictive model, the general practitioner could decide if hospitalization was necessary or not.\nMAIN OUTCOME MEASUREMENTS: Identification of patients at low (stable angina, atypical chest pain, other pathology) and high (myocardial infarction, unstable angina) probability of acute cardiac pathology.\nRESULTS: Among 977 patients with a complete pre-hospital evaluation in the validation phase of the study, the decision rule recommended 'no hospitalization' in 227 patients (23%). The general practitioner followed this advice in 44% of these patients. Although seven of them developed a non-Q wave myocardial infarction, no complications occurred in patients not admitted. In addition, the general practitioner did not hospitalize 19 (2%) of 750 patients for whom the decision rule recommended admission. Pre-hospital triage by the general practitioner resulted in a 12% (118 of 977 patients) reduction of the number of patients admitted to the Coronary Care Units.\nCONCLUSIONS: Pre-hospital triage by the general practitioner was facilitated using a standardized questionnaire and pre-hospital electrocardiography, and resulted in a reduction in the number of patients admitted to the Coronary Care Unit, and proved to be safe.","container-title":"European Heart Journal","ISSN":"0195-668X","issue":"1","journalAbbreviation":"Eur. Heart J.","language":"eng","note":"PMID: 8682136","page":"89-95","source":"PubMed","title":"Implementation of a pre-hospital decision rule in general practice. Triage of patients with suspected myocardial infarction","volume":"17","author":[{"family":"Grijseels","given":"E. W."},{"family":"Deckers","given":"J. W."},{"family":"Hoes","given":"A. W."},{"family":"Boersma","given":"E."},{"family":"Hartman","given":"J. A."},{"family":"Does","given":"E.","non-dropping-particle":"van der"},{"family":"Simoons","given":"M. L."}],"issued":{"date-parts":[["1996",1]]}}}],"schema":""} 16,31–33,35, and biomarkers were used in just two studies ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"siQoswoR","properties":{"formattedCitation":"\\super 16,35\\nosupersub{}","plainCitation":"16,35","noteIndex":0},"citationItems":[{"id":439,"uris":[""],"uri":[""],"itemData":{"id":439,"type":"article-journal","abstract":"BACKGROUND: The first study of the FamouS Triage project investigates the feasibility of ruling out a myocardial infarction in pre-hospital chest pain patients without electrocardiographic ST-segment elevation by using the modified HEART score at the patient's home, incorporating only a single highly sensitive troponin T measurement.\nMETHODS: A venous blood sample was drawn in the ambulance from 1127 consecutive chest pain patients for measurement of the pre-hospital highly sensitive troponin T levels, in order to establish a pre-hospital HEART score (i.e. the modified HEART score) and evaluate the possibility of triage at the patient's home. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) i.e. acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or death within 30 days after initial presentation.\nRESULTS: Two hundred and six patients (18%) developed a MACE during 30 days of follow-up. Thirty-six per cent of the patients ( n=403) had a low modified HEART score (0-3 points) and none of them developed a MACE during follow-up. Forty-four per cent of the patients ( n=494) had an intermediate modified HEART score (4-6 points) and 18% of them developed a MACE. Twenty per cent of the patients ( n=230) had a high modified HEART score (7-10 points) of which 52% developed a MACE during follow-up.\nCONCLUSION: It seems feasible to rule out a myocardial infarction at home in chest pain patients without ST-segment elevation by using the modified HEART score.\nTRIAL ID: NTR4205. Dutch Trial Register [ ]: trial number 4205.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872616687116","ISSN":"2048-8734","issue":"2","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 28084079","page":"102-110","source":"PubMed","title":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score","title-short":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage)","volume":"7","author":[{"family":"Ishak","given":"Maycel"},{"family":"Ali","given":"Danish"},{"family":"Fokkert","given":"Marion J."},{"family":"Slingerland","given":"Robbert J."},{"family":"Tolsma","given":"Rudolf T."},{"family":"Badings","given":"Erik"},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Eenennaam","given":"Fred","non-dropping-particle":"van"},{"family":"Mosterd","given":"Arend"},{"family":"Ten Berg","given":"Jurri?n M."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"}],"issued":{"date-parts":[["2018",3]]}}},{"id":435,"uris":[""],"uri":[""],"itemData":{"id":435,"type":"article-journal","abstract":"BACKGROUND:: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE).\nMETHODS:: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ? 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death.\nRESULTS:: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%).\nCONCLUSIONS:: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872618813846","ISSN":"2048-8734","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 30468395","page":"2048872618813846","source":"PubMed","title":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study","title-short":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome","author":[{"family":"Dongen","given":"Dominique N.","non-dropping-particle":"van"},{"family":"Tolsma","given":"Rudolf T."},{"family":"Fokkert","given":"Marion J."},{"family":"Badings","given":"Erik A."},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Slingerland","given":"Robbert J."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"},{"family":"Ottervanger","given":"Jan Paul"}],"issued":{"date-parts":[["2018",11,23]]}}}],"schema":""} 16,35. Interestingly, in the two studies ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"dA1N6Xrz","properties":{"formattedCitation":"\\super 16,35\\nosupersub{}","plainCitation":"16,35","noteIndex":0},"citationItems":[{"id":439,"uris":[""],"uri":[""],"itemData":{"id":439,"type":"article-journal","abstract":"BACKGROUND: The first study of the FamouS Triage project investigates the feasibility of ruling out a myocardial infarction in pre-hospital chest pain patients without electrocardiographic ST-segment elevation by using the modified HEART score at the patient's home, incorporating only a single highly sensitive troponin T measurement.\nMETHODS: A venous blood sample was drawn in the ambulance from 1127 consecutive chest pain patients for measurement of the pre-hospital highly sensitive troponin T levels, in order to establish a pre-hospital HEART score (i.e. the modified HEART score) and evaluate the possibility of triage at the patient's home. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) i.e. acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or death within 30 days after initial presentation.\nRESULTS: Two hundred and six patients (18%) developed a MACE during 30 days of follow-up. Thirty-six per cent of the patients ( n=403) had a low modified HEART score (0-3 points) and none of them developed a MACE during follow-up. Forty-four per cent of the patients ( n=494) had an intermediate modified HEART score (4-6 points) and 18% of them developed a MACE. Twenty per cent of the patients ( n=230) had a high modified HEART score (7-10 points) of which 52% developed a MACE during follow-up.\nCONCLUSION: It seems feasible to rule out a myocardial infarction at home in chest pain patients without ST-segment elevation by using the modified HEART score.\nTRIAL ID: NTR4205. Dutch Trial Register [ ]: trial number 4205.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872616687116","ISSN":"2048-8734","issue":"2","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 28084079","page":"102-110","source":"PubMed","title":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score","title-short":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage)","volume":"7","author":[{"family":"Ishak","given":"Maycel"},{"family":"Ali","given":"Danish"},{"family":"Fokkert","given":"Marion J."},{"family":"Slingerland","given":"Robbert J."},{"family":"Tolsma","given":"Rudolf T."},{"family":"Badings","given":"Erik"},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Eenennaam","given":"Fred","non-dropping-particle":"van"},{"family":"Mosterd","given":"Arend"},{"family":"Ten Berg","given":"Jurri?n M."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"}],"issued":{"date-parts":[["2018",3]]}}},{"id":435,"uris":[""],"uri":[""],"itemData":{"id":435,"type":"article-journal","abstract":"BACKGROUND:: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE).\nMETHODS:: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ? 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death.\nRESULTS:: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%).\nCONCLUSIONS:: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872618813846","ISSN":"2048-8734","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 30468395","page":"2048872618813846","source":"PubMed","title":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study","title-short":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome","author":[{"family":"Dongen","given":"Dominique N.","non-dropping-particle":"van"},{"family":"Tolsma","given":"Rudolf T."},{"family":"Fokkert","given":"Marion J."},{"family":"Badings","given":"Erik A."},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Slingerland","given":"Robbert J."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"},{"family":"Ottervanger","given":"Jan Paul"}],"issued":{"date-parts":[["2018",11,23]]}}}],"schema":""} 16,35 that used all four components (the ECG, a point-of-care biomarker, patient history and vital signs/examinations), both achieved high sensitivity (100% and 96%) and negative predictive value (100% and 97%) but poor specificity (43% and 29%) and positive predictive value (29% and 21%). However, both studies excluded patients with clear ST elevation, thus focusing on the risk stratification of patients between ACS and non-ACS rather than triage of patients with NSTEMI or STEMI. Three of the studies ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"akXD8Vvi","properties":{"formattedCitation":"\\super 20,31,34\\nosupersub{}","plainCitation":"20,31,34","noteIndex":0},"citationItems":[{"id":220,"uris":[""],"uri":[""],"itemData":{"id":220,"type":"article-journal","abstract":"OBJECTIVE: ST-elevation myocardial infarction (STEMI) identification by emergency medicine services (EMS) leading to pre-hospital catheterization laboratory (CL) activation shortens ischemic time and improves outcomes. We examined the incremental value of addition of a screening clinical tool (CT), containing clinical information and a Zoll electrocardiogram (ECG)-resident STEMI identification program (ZI) to ZI alone.\nMETHODS: All EMS-performed and ZI-analyzed ECGs transmitted to a percutaneous coronary intervention hospital from October 2009 to January 2011 were reviewed for diagnostic accuracy. ZI performance was also compared to ECG interpretations by 2 experienced readers The CT was then retrospectively applied to determine the incremental benefit above the ZI alone.\nRESULTS: ST-elevation myocardial infarction was confirmed in 23 (7.5%) of 305 patients. ZI was positive in 37 (12.1%): sensitivity: 95.6% and specificity: 94.6%, positive predictive value (PPV), 59.5%, negative predictive value (NPV), 99.6%, and accuracy of 93.8%. Moderate agreement was observed among the readers and ZI. CT criteria for CL activation were met in 24 (7.8%): 20 (83.3%) were confirmed STEMIs: sensitivity: 86.9%, specificity: 98.5%, a PPV: 83.3%, and NPV: 98.6%, accuracy of 97.7%. CT + ZI increased PPV (P<0.05) and specificity (P<0.003) by reducing false positive STEMI identifications from 15 (4.9%) to 4 (1.3%).\nCONCLUSIONS: In an urban cohort of all EMS transmitted ECGs, ZI has high sensitivity and specificity for STEMI identification. Whereas the PPV was low, reflecting both low STEMI prevalence and presence of STEMI-mimics, the NPV was very high. These findings suggest that a simplified CT combined with computer STEMI interpretation can identify patients for pre-hospital CL activation. Confirmation of these results could improve the design of STEMI care systems.","container-title":"The American Journal of Emergency Medicine","DOI":"10.1016/j.ajem.2013.04.013","ISSN":"1532-8171","issue":"7","journalAbbreviation":"Am J Emerg Med","language":"eng","note":"PMID: 23706572","page":"1098-1102","source":"PubMed","title":"An algorithm for identification of ST-elevation myocardial infarction patients by emergency medicine services","volume":"31","author":[{"family":"Wilson","given":"Ryan E."},{"family":"Kado","given":"Herman S."},{"family":"Percy","given":"Robert F."},{"family":"Butterfield","given":"Ryan C."},{"family":"Sabato","given":"Joseph"},{"family":"Strom","given":"Joel A."},{"family":"Box","given":"Lyndon C."}],"issued":{"date-parts":[["2013",7]]}}},{"id":445,"uris":[""],"uri":[""],"itemData":{"id":445,"type":"article-journal","abstract":"BACKGROUND: Identifying ST-segment elevation myocardial infarctions (STEMIs) in the field can decrease door-to-balloon times. Paramedics may use a computer algorithm to help them interpret prehospital electrocariograms (ECGs). It is unknown how accurately the computer can identify STEMIs.\nOBJECTIVES: To Determine the sensitivity and specificity of prehospital ECGs in identifying patients with STEMI.\nMETHODS: Retrospective cross-sectional study of 200 prehospital ECGs acquired using Lifepak 12 monitors and transmitted by one of more than 20 emergency medical services (EMS) agencies to the emergency department (ED) of a Summa Akron City Hospital, a level 1 trauma center between January 1, 2007, and February 18, 2010. The ED sees more than 73,000 adult patients and treats 120 STEMIs annually. The laboratory performs 3,400 catheterizations annually. The first 100 patients with a diagnosis of STEMI and cardiac catheterization laboratory activation from the ED were analyzed. For comparison, a control group of 100 other ECGs from patients without a STEMI were randomly selected from our Medtronic database using a random-number generator. For patients with STEMI, an accurate computer interpretation was \"acute MI suspected.\" Other interpretations were counted as misses. Specificity and sensitivity were calculated with confidence intervals (CIs). The sample size was determined a priori for a 95% CI of ±10%.\nRESULTS: Zero control patients were incorrectly labeled \"acute MI suspected.\" The specificity was 100% (100/100; 95% CI 0.96-1.0), whereas the sensitivity was 58% (58/100; 95% CI 0.48-0.67). This would have resulted in 42 missed cardiac catheterization laboratory activations, but zero inappropriate activations. The most common incorrect interpretation of STEMI ECGs by the computer was \"data quality prohibits interpretation,\" followed by \"abnormal ECG unconfirmed.\"\nCONCLUSIONS: Prehospital computer interpretation is not sensitive for STEMI identification and should not be used as a single method for prehospital activation of the cardiac catheterizing laboratory. Because of its high specificity, it may serve as an adjunct to interpretation.","container-title":"Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors","DOI":"10.3109/10903127.2012.722176","ISSN":"1545-0066","issue":"2","journalAbbreviation":"Prehosp Emerg Care","language":"eng","note":"PMID: 23066910","page":"211-216","source":"PubMed","title":"Prehospital electrocardiographic computer identification of ST-segment elevation myocardial infarction","volume":"17","author":[{"family":"Bhalla","given":"Mary Colleen"},{"family":"Mencl","given":"Francis"},{"family":"Gist","given":"Mikki Amber"},{"family":"Wilber","given":"Scott"},{"family":"Zalewski","given":"Jon"}],"issued":{"date-parts":[["2013",6]]}}},{"id":437,"uris":[""],"uri":[""],"itemData":{"id":437,"type":"article-journal","abstract":"BACKGROUND: The purposes of this study were to create a new flow-chart of prehospital electrocardiography (ECG)-transmission, evaluate its predictive ability for ST-elevation myocardial infarction (STEMI) and shorten door-to-balloon time (DTBT).\nMETHOD AND RESULTS: The new transmission flow-chart was created using symptoms from previous medical records of STEMI patients. A total of 4090 consecutive patients transferred emergently to our hospital were divided into two groups: those in ambulances with an ECG-transmission device with the new flow-chart (ECGT-FC) and those transferred without an ECG-transmission device (non-ECGT) groups. A STEMI group comprising walk-in patients during the same period was used as a control group. The predictive ability of STEMI and the effectiveness of shortening the DTBT by the new flow-chart of ECG-transmission was evaluated. In the ECGT-FC group, the prevalence of STEMI in the ECG-transmission by the new flow-chart were significantly higher than in the non-ECG-transmission patients (6.71% vs. 0.19%; p<0.001). The sensitivity and specificity of the new ECG-transmission flow-chart were 83.3% and 88.1%, respectively. The median DTBT was significantly shortened (p=0.045) and the prevalence of DTBT<90min was significantly higher in the ECGT-FC group (p=0.018) than the other groups.\nCONCLUSION: The sensitivity and specificity of the new flow-chart for ECG-transmission were high. The new flow-chart combined with an ECG-transmission device could detect STEMI efficiently and shorten DTBT.","container-title":"Journal of Cardiology","DOI":"10.1016/j.jjcc.2018.03.011","ISSN":"1876-4738","issue":"4","journalAbbreviation":"J Cardiol","language":"eng","note":"PMID: 29804908","page":"335-342","source":"PubMed","title":"Predictive ability and efficacy for shortening door-to-balloon time of a new prehospital electrocardiogram-transmission flow chart in patients with ST-elevation myocardial infarction - Results of the CASSIOPEIA study","volume":"72","author":[{"family":"Sakai","given":"Toshiaki"},{"family":"Nishiyama","given":"Osamu"},{"family":"Onodera","given":"Masayuki"},{"family":"Matsuda","given":"Shigekatsu"},{"family":"Wakisawa","given":"Shinobu"},{"family":"Nakamura","given":"Motoyuki"},{"family":"Morino","given":"Yoshihiro"},{"family":"Itoh","given":"Tomonori"},{"literal":"CASSIOPEIA study group"}],"issued":{"date-parts":[["2018",10]]}}}],"schema":""} 20,31,34 looked exclusively at the identification of STEMI and had a larger range of specificity (88% to 100%) and positive predictive value (7% to 100%). The heterogeneity of the findings appears to be dependent on the aim of a pre-hospital CDSS to differentiate between a ‘rule-in/out’ for ACS, or between NSTEMI and STEMI. Recent advances have allowed the use of high-sensitivity troponins to achieve a high degree of sensitivity in the diagnosis of ACS, leading to the reduction of unstable angina diagnosis ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"umLOvMuZ","properties":{"formattedCitation":"\\super 38\\nosupersub{}","plainCitation":"38","noteIndex":0},"citationItems":[{"id":409,"uris":[""],"uri":[""],"itemData":{"id":409,"type":"article-journal","abstract":"BACKGROUND: Suspected acute coronary syndrome is the commonest reason for emergency admission to hospital and is a large burden on health-care resources. Strategies to identify low-risk patients suitable for immediate discharge would have major benefits.\nMETHODS: We did a prospective cohort study of 6304 consecutively enrolled patients with suspected acute coronary syndrome presenting to four secondary and tertiary care hospitals in Scotland. We measured plasma troponin concentrations at presentation using a high-sensitivity cardiac troponin I assay. In derivation and validation cohorts, we evaluated the negative predictive value of a range of troponin concentrations for the primary outcome of index myocardial infarction, or subsequent myocardial infarction or cardiac death at 30 days. This trial is registered with (number NCT01852123).\nFINDINGS: 782 (16%) of 4870 patients in the derivation cohort had index myocardial infarction, with a further 32 (1%) re-presenting with myocardial infarction and 75 (2%) cardiac deaths at 30 days. In patients without myocardial infarction at presentation, troponin concentrations were less than 5 ng/L in 2311 (61%) of 3799 patients, with a negative predictive value of 99·6% (95% CI 99·3-99·8) for the primary outcome. The negative predictive value was consistent across groups stratified by age, sex, risk factors, and previous cardiovascular disease. In two independent validation cohorts, troponin concentrations were less than 5 ng/L in 594 (56%) of 1061 patients, with an overall negative predictive value of 99·4% (98·8-99·9). At 1 year, these patients had a lower risk of myocardial infarction and cardiac death than did those with a troponin concentration of 5 ng/L or more (0·6% vs 3·3%; adjusted hazard ratio 0·41, 95% CI 0·21-0·80; p<0·0001).\nINTERPRETATION: Low plasma troponin concentrations identify two-thirds of patients at very low risk of cardiac events who could be discharged from hospital. Implementation of this approach could substantially reduce hospital admissions and have major benefits for both patients and health-care providers.\nFUNDING: British Heart Foundation and Chief Scientist Office (Scotland).","container-title":"Lancet (London, England)","DOI":"10.1016/S0140-6736(15)00391-8","ISSN":"1474-547X","issue":"10012","journalAbbreviation":"Lancet","language":"eng","note":"PMID: 26454362\nPMCID: PMC4765710","page":"2481-2488","source":"PubMed","title":"High-sensitivity cardiac troponin I at presentation in patients with suspected acute coronary syndrome: a cohort study","title-short":"High-sensitivity cardiac troponin I at presentation in patients with suspected acute coronary syndrome","volume":"386","author":[{"family":"Shah","given":"Anoop S. V."},{"family":"Anand","given":"Atul"},{"family":"Sandoval","given":"Yader"},{"family":"Lee","given":"Kuan Ken"},{"family":"Smith","given":"Stephen W."},{"family":"Adamson","given":"Philip D."},{"family":"Chapman","given":"Andrew R."},{"family":"Langdon","given":"Timothy"},{"family":"Sandeman","given":"Dennis"},{"family":"Vaswani","given":"Amar"},{"family":"Strachan","given":"Fiona E."},{"family":"Ferry","given":"Amy"},{"family":"Stirzaker","given":"Alexandra G."},{"family":"Reid","given":"Alan"},{"family":"Gray","given":"Alasdair J."},{"family":"Collinson","given":"Paul O."},{"family":"McAllister","given":"David A."},{"family":"Apple","given":"Fred S."},{"family":"Newby","given":"David E."},{"family":"Mills","given":"Nicholas L."},{"literal":"High-STEACS investigators"}],"issued":{"date-parts":[["2015",12,19]]}}}],"schema":""} 38. One of the studies reviewed demonstrated that there is the capability of the traditional point-of-care troponin to be used in CDSS ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"WMagVn04","properties":{"formattedCitation":"\\super 16\\nosupersub{}","plainCitation":"16","noteIndex":0},"citationItems":[{"id":435,"uris":[""],"uri":[""],"itemData":{"id":435,"type":"article-journal","abstract":"BACKGROUND:: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE).\nMETHODS:: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ? 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death.\nRESULTS:: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%).\nCONCLUSIONS:: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872618813846","ISSN":"2048-8734","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 30468395","page":"2048872618813846","source":"PubMed","title":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study","title-short":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome","author":[{"family":"Dongen","given":"Dominique N.","non-dropping-particle":"van"},{"family":"Tolsma","given":"Rudolf T."},{"family":"Fokkert","given":"Marion J."},{"family":"Badings","given":"Erik A."},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Slingerland","given":"Robbert J."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"},{"family":"Ottervanger","given":"Jan Paul"}],"issued":{"date-parts":[["2018",11,23]]}}}],"schema":""} 16. However, there were issues reported with the test used in this study, including device errors, inability to obtain blood, and the risk of false negatives when samples were taken shortly after symptom onset. The study was also limited by the use of a single troponin value in isolation, where clinicians are unable to observe any trends and a raised troponin does not always indicate myocardial ischaemia but may be a result of myocardial injury ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"aZktec0H","properties":{"formattedCitation":"\\super 27\\nosupersub{}","plainCitation":"27","noteIndex":0},"citationItems":[{"id":307,"uris":[""],"uri":[""],"itemData":{"id":307,"type":"article-journal","container-title":"European Heart Journal","DOI":"10.1093/eurheartj/ehy462","ISSN":"1522-9645","journalAbbreviation":"Eur. Heart J.","language":"eng","note":"PMID: 30165617","source":"PubMed","title":"Fourth universal definition of myocardial infarction (2018)","author":[{"family":"Thygesen","given":"Kristian"},{"family":"Alpert","given":"Joseph S."},{"family":"Jaffe","given":"Allan S."},{"family":"Chaitman","given":"Bernard R."},{"family":"Bax","given":"Jeroen J."},{"family":"Morrow","given":"David A."},{"family":"White","given":"Harvey D."},{"literal":"ESC Scientific Document Group"}],"issued":{"date-parts":[["2018",8,25]]}}}],"schema":""} 27. A computer-based machine learning algorithm for the diagnosis of MI has been developed with a paired troponin, analysing the rate of change of troponin along with age and sex showing strong sensitivity at 97.8% and specificity of 92.2% ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"KrdHN8pJ","properties":{"formattedCitation":"\\super 39\\nosupersub{}","plainCitation":"39","noteIndex":0},"citationItems":[{"id":713,"uris":[""],"uri":[""],"itemData":{"id":713,"type":"article-journal","abstract":"BACKGROUND: Variations in cardiac troponin concentrations by age, sex and time between samples in patients with suspected myocardial infarction are not currently accounted for in diagnostic approaches. We aimed to combine these variables through machine learning to improve the assessment of risk for individual patients.\nMETHODS: A machine learning algorithm (myocardial-ischemic-injury-index [MI3]) incorporating age, sex, and paired high-sensitivity cardiac troponin I concentrations, was trained on 3,013 patients and tested on 7,998 patients with suspected myocardial infarction. MI3 uses gradient boosting to compute a value (0-100) reflecting an individual's likelihood of a diagnosis of type 1 myocardial infarction and estimates the sensitivity, negative predictive value (NPV), specificity and positive predictive value (PPV) for that individual. Assessment was by calibration and area under the receiver-operating-characteristic curve (AUC). Secondary analysis evaluated example MI3 thresholds from the training set that identified patients as low-risk (99% sensitivity) and high-risk (75% PPV), and performance at these thresholds was compared in the test set to the 99th percentile and European Society of Cardiology (ESC) rule-out pathways.\nRESULTS: Myocardial infarction occurred in 404 (13.4%) patients in the training set and 849 (10.6%) patients in the test set. MI3 was well calibrated with a very high AUC of 0.963 [0.956-0.971] in the test set and similar performance in early and late presenters. Example MI3 thresholds identifying low-risk and high-risk patients in the training set were 1.6 and 49.7 respectively. In the test set, MI3 values were <1.6 in 69.5% with a NPV of 99.7% (99.5%-99.8%) and sensitivity of 97.8% (96.7-98.7%), and were ≥49.7 in 10.6% with a PPV of 71.8% (68.9-75.0%) and specificity of 96.7% (96.3-97.1%). Using these thresholds, MI3 performed better than the ESC 0/3-hour pathway (sensitivity 82.5% [74.5-88.8%], specificity 92.2% [90.7-93.5%]) and the 99th percentile at any time-point (sensitivity 89.6% [87.4-91.6%]), specificity 89.3% [88.6-90.0%]).\nCONCLUSIONS: Using machine learning, MI3 provides an individualized and objective assessment of the likelihood of myocardial infarction, which can be used to identify low-risk and high-risk patients who may benefit from earlier clinical decisions.\nCLINICAL TRIAL REGISTRATION: Unique Identifier: Australian New Zealand Clinical Trials Registry: ACTRN12616001441404. URL: .","container-title":"Circulation","DOI":"10.1161/CIRCULATIONAHA.119.041980","ISSN":"1524-4539","journalAbbreviation":"Circulation","language":"eng","note":"PMID: 31416346\nPMCID: PMC6749969","source":"PubMed","title":"Machine Learning to Predict the Likelihood of Acute Myocardial Infarction","author":[{"family":"Than","given":"Martin P."},{"family":"Pickering","given":"John W."},{"family":"Sandoval","given":"Yader"},{"family":"Shah","given":"Anoop S. V."},{"family":"Tsanas","given":"Athanasios"},{"family":"Apple","given":"Fred S."},{"family":"Blankenberg","given":"Stefan"},{"family":"Cullen","given":"Louise"},{"family":"Mueller","given":"Christian"},{"family":"Neumann","given":"Johannes T."},{"family":"Twerenbold","given":"Raphael"},{"family":"Westermann","given":"Dirk"},{"family":"Beshiri","given":"Agim"},{"family":"Mills","given":"Nicholas L."},{"literal":"MI3 collaborative"}],"issued":{"date-parts":[["2019",8,16]]}}}],"schema":""} 39. However, the study required a second troponin at 1-3 hours following the initial troponin measurement and therefore would not be feasible in the pre-hospital environment. The value of an isolated troponin in the pre-hospital situation maybe more apparent in combination with other components of CDSS such as patient history and suggestive ECG features. In addition, the use of pre-hospital high-sensitivity troponin tests in comparison to the in-hospital test may aid in the sensitivity when identifying ACS where shorter time from symptom onset to test can reduce sensitivity ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"fuXlmpLH","properties":{"formattedCitation":"\\super 40\\nosupersub{}","plainCitation":"40","noteIndex":0},"citationItems":[{"id":459,"uris":[""],"uri":[""],"itemData":{"id":459,"type":"article-journal","abstract":"Around one million patients present to hospital with chest pain every year, accounting for approximately 5% of all emergency department attendances in the UK. However, only one in five patients are found to have had a myocardial infarction.1 Therefore, for several years, there has been a drive to develop diagnostic strategies which allow accurate identification of patients without myocardial infarction at an earlier stage, who may not require admission to hospital for serial cardiac biomarker testing. Such strategies have the potential to improve patient experience and optimise resource allocation both in the emergency department and in hospital, at a time of ever-increasing demands.Cardiac troponin is the biomarker of choice for the detection of myocardial injury, and international guidelines recommend concentrations are measured using a high-sensitivity assay.2 While high-sensitivity assays were first introduced in Europe in 2010, they have only recently become available for use in clinical practice in the USA. The higher precision and lower limits of detection afforded by these tests has facilitated the development of pathways which can rule out myocardial infarction at an earlier stage, the majority of which have demonstrated a magnitude of?benefits in diagnostic accuracy compared with using the recommended diagnostic threshold (99th centile) alone.3 4 In practical terms, implementation of these approaches requires investment in infrastructure to deliver accurate and timely cardiac troponin results on a high-sensitivity platform which is not always available.One potential strategy to improve …","container-title":"Heart","DOI":"10.1136/heartjnl-2018-314306","journalAbbreviation":"Heart","page":"heartjnl-2018-314306","title":"Contemporary point of care cardiac troponin testing in suspected acute coronary syndrome","author":[{"family":"Chapman","given":"Andrew R"},{"family":"Stewart","given":"Stacey"},{"family":"Mills","given":"Nicholas L"}],"issued":{"date-parts":[["2019",2,6]]}}}],"schema":""} 40. The use of contemporary risk stratification algorithms for MI has been shown to be effective following hospital admission, with examples like the HEART, TIMI, and GRACE scores ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"378JPQBq","properties":{"formattedCitation":"\\super 41\\uc0\\u8211{}43\\nosupersub{}","plainCitation":"41–43","noteIndex":0},"citationItems":[{"id":461,"uris":[""],"uri":[""],"itemData":{"id":461,"type":"article-journal","abstract":"OBJECTIVE: The HEART score for the early risk stratification of patients presenting to the emergency department with chest pain contains 5 elements: history, electrocardiogram, age, risk factors, and troponin. It has been validated in The Netherlands. The purpose of this investigation was to perform an external validation of the HEART score in an Asia-Pacific population.\nMETHODS: Data were used from 2906 patients presenting with chest pain to the emergency departments of 14 hospitals. HEART scores were determined retrospectively. Three risk groups were composed based on previous research. The predictive values for the occurrence of 30-day major adverse coronary events (MACE) were assessed. A comparison was made with the Thrombolysis in Myocardial Infarction (TIMI) score in terms of the value of C-statistics.\nRESULTS: The low-risk group, HEART score ≤ 3, consisted of 820/2906 patients (28.2%). Fourteen (1.7%) patients were incorrectly defined as low risk (false negatives). The high-risk population, HEART score 7-10, consisted of 464 patients (16%) with a risk of MACE of 43.1%. The C-statistics were 0.83 (0.81-0.85) for HEART and 0.75 (0.72-0.77) for TIMI (P < 0.01).\nCONCLUSIONS: Utilization of the HEART score provided excellent determination of risk for 30-day MACE, comparing well with the Thrombolysis in Myocardial Infarction score. This study externally validates previous findings that HEART is a powerful clinical tool in this setting. It quickly identifies both a large proportion of low-risk patients, in whom early discharge without additional testing goes with a risk of MACE of only 1.7%, and high-risk patients who are potential candidates for early invasive strategies.","container-title":"Critical Pathways in Cardiology","DOI":"10.1097/HPC.0b013e31828b327e","ISSN":"1535-2811","issue":"3","journalAbbreviation":"Crit Pathw Cardiol","language":"eng","note":"PMID: 23892941","page":"121-126","source":"PubMed","title":"The HEART score for the assessment of patients with chest pain in the emergency department: a multinational validation study","title-short":"The HEART score for the assessment of patients with chest pain in the emergency department","volume":"12","author":[{"family":"Six","given":"A. Jacob"},{"family":"Cullen","given":"Louise"},{"family":"Backus","given":"Barbra E."},{"family":"Greenslade","given":"Jaimi"},{"family":"Parsonage","given":"William"},{"family":"Aldous","given":"Sally"},{"family":"Doevendans","given":"Pieter A."},{"family":"Than","given":"Martin"}],"issued":{"date-parts":[["2013",9]]}}},{"id":463,"uris":[""],"uri":[""],"itemData":{"id":463,"type":"article-journal","abstract":"CONTEXT: Patients with unstable angina/non-ST-segment elevation myocardial infarction (MI) (UA/NSTEMI) present with a wide spectrum of risk for death and cardiac ischemic events.\nOBJECTIVE: To develop a simple risk score that has broad applicability, is easily calculated at patient presentation, does not require a computer, and identifies patients with different responses to treatments for UA/NSTEMI.\nDESIGN, SETTING, AND PATIENTS: Two phase 3, international, randomized, double-blind trials (the Thrombolysis in Myocardial Infarction [TIMI] 11B trial [August 1996-March 1998] and the Efficacy and Safety of Subcutaneous Enoxaparin in Unstable Angina and Non-Q-Wave MI trial [ESSENCE; October 1994-May 1996]). A total of 1957 patients with UA/NSTEMI were assigned to receive unfractionated heparin (test cohort) and 1953 to receive enoxaparin in TIMI 11B; 1564 and 1607 were assigned respectively in ESSENCE. The 3 validation cohorts were the unfractionated heparin group from ESSENCE and both enoxaparin groups.\nMAIN OUTCOME MEASURES: The TIMI risk score was derived in the test cohort by selection of independent prognostic variables using multivariate logistic regression, assignment of value of 1 when a factor was present and 0 when it was absent, and summing the number of factors present to categorize patients into risk strata. Relative differences in response to therapeutic interventions were determined by comparing the slopes of the rates of events with increasing score in treatment groups and by testing for an interaction between risk score and treatment. Outcomes were TIMI risk score for developing at least 1 component of the primary end point (all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization) through 14 days after randomization.\nRESULTS: The 7 TIMI risk score predictor variables were age 65 years or older, at least 3 risk factors for coronary artery disease, prior coronary stenosis of 50% or more, ST-segment deviation on electrocardiogram at presentation, at least 2 anginal events in prior 24 hours, use of aspirin in prior 7 days, and elevated serum cardiac markers. Event rates increased significantly as the TIMI risk score increased in the test cohort in TIMI 11B: 4.7% for a score of 0/1; 8.3% for 2; 13. 2% for 3; 19.9% for 4; 26.2% for 5; and 40.9% for 6/7 (P<.001 by chi(2) for trend). The pattern of increasing event rates with increasing TIMI risk score was confirmed in all 3 validation groups (P<.001). The slope of the increase in event rates with increasing numbers of risk factors was significantly lower in the enoxaparin groups in both TIMI 11B (P =.01) and ESSENCE (P =.03) and there was a significant interaction between TIMI risk score and treatment (P =. 02).\nCONCLUSIONS: In patients with UA/NSTEMI, the TIMI risk score is a simple prognostication scheme that categorizes a patient's risk of death and ischemic events and provides a basis for therapeutic decision making. JAMA. 2000;284:835-842","container-title":"JAMA","ISSN":"0098-7484","issue":"7","journalAbbreviation":"JAMA","language":"eng","note":"PMID: 10938172","page":"835-842","source":"PubMed","title":"The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making","title-short":"The TIMI risk score for unstable angina/non-ST elevation MI","volume":"284","author":[{"family":"Antman","given":"E. M."},{"family":"Cohen","given":"M."},{"family":"Bernink","given":"P. J."},{"family":"McCabe","given":"C. H."},{"family":"Horacek","given":"T."},{"family":"Papuchis","given":"G."},{"family":"Mautner","given":"B."},{"family":"Corbalan","given":"R."},{"family":"Radley","given":"D."},{"family":"Braunwald","given":"E."}],"issued":{"date-parts":[["2000",8,16]]}}},{"id":465,"uris":[""],"uri":[""],"itemData":{"id":465,"type":"article-journal","abstract":"OBJECTIVE: To develop a clinical risk prediction tool for estimating the cumulative six month risk of death and death or myocardial infarction to facilitate triage and management of patients with acute coronary syndrome.\nDESIGN: Prospective multinational observational study in which we used multivariable regression to develop a final predictive model, with prospective and external validation.\nSETTING: Ninety four hospitals in 14 countries in Europe, North and South America, Australia, and New Zealand.\nPOPULATION: 43,810 patients (21,688 in derivation set; 22,122 in validation set) presenting with acute coronary syndrome with or without ST segment elevation enrolled in the global registry of acute coronary events (GRACE) study between April 1999 and September 2005.\nMAIN OUTCOME MEASURES: Death and myocardial infarction.\nRESULTS: 1989 patients died in hospital, 1466 died between discharge and six month follow-up, and 2793 sustained a new non-fatal myocardial infarction. Nine factors independently predicted death and the combined end point of death or myocardial infarction in the period from admission to six months after discharge: age, development (or history) of heart failure, peripheral vascular disease, systolic blood pressure, Killip class, initial serum creatinine concentration, elevated initial cardiac markers, cardiac arrest on admission, and ST segment deviation. The simplified model was robust, with prospectively validated C-statistics of 0.81 for predicting death and 0.73 for death or myocardial infarction from admission to six months after discharge. The external applicability of the model was validated in the dataset from GUSTO IIb (global use of strategies to open occluded coronary arteries).\nCONCLUSIONS: This risk prediction tool uses readily identifiable variables to provide robust prediction of the cumulative six month risk of death or myocardial infarction. It is a rapid and widely applicable method for assessing cardiovascular risk to complement clinical assessment and can guide patient triage and management across the spectrum of patients with acute coronary syndrome.","container-title":"BMJ (Clinical research ed.)","DOI":"10.1136/bmj.38985.646481.55","ISSN":"1756-1833","issue":"7578","journalAbbreviation":"BMJ","language":"eng","note":"PMID: 17032691\nPMCID: PMC1661748","page":"1091","source":"PubMed","title":"Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE)","title-short":"Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome","volume":"333","author":[{"family":"Fox","given":"Keith A. A."},{"family":"Dabbous","given":"Omar H."},{"family":"Goldberg","given":"Robert J."},{"family":"Pieper","given":"Karen S."},{"family":"Eagle","given":"Kim A."},{"family":"Van de Werf","given":"Frans"},{"family":"Avezum","given":"Alvaro"},{"family":"Goodman","given":"Shaun G."},{"family":"Flather","given":"Marcus D."},{"family":"Anderson","given":"Frederick A."},{"family":"Granger","given":"Christopher B."}],"issued":{"date-parts":[["2006",11,25]]}}}],"schema":""} 41–43. Two studies ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"c8aIPC43","properties":{"formattedCitation":"\\super 16,35\\nosupersub{}","plainCitation":"16,35","noteIndex":0},"citationItems":[{"id":439,"uris":[""],"uri":[""],"itemData":{"id":439,"type":"article-journal","abstract":"BACKGROUND: The first study of the FamouS Triage project investigates the feasibility of ruling out a myocardial infarction in pre-hospital chest pain patients without electrocardiographic ST-segment elevation by using the modified HEART score at the patient's home, incorporating only a single highly sensitive troponin T measurement.\nMETHODS: A venous blood sample was drawn in the ambulance from 1127 consecutive chest pain patients for measurement of the pre-hospital highly sensitive troponin T levels, in order to establish a pre-hospital HEART score (i.e. the modified HEART score) and evaluate the possibility of triage at the patient's home. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) i.e. acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or death within 30 days after initial presentation.\nRESULTS: Two hundred and six patients (18%) developed a MACE during 30 days of follow-up. Thirty-six per cent of the patients ( n=403) had a low modified HEART score (0-3 points) and none of them developed a MACE during follow-up. Forty-four per cent of the patients ( n=494) had an intermediate modified HEART score (4-6 points) and 18% of them developed a MACE. Twenty per cent of the patients ( n=230) had a high modified HEART score (7-10 points) of which 52% developed a MACE during follow-up.\nCONCLUSION: It seems feasible to rule out a myocardial infarction at home in chest pain patients without ST-segment elevation by using the modified HEART score.\nTRIAL ID: NTR4205. Dutch Trial Register [ ]: trial number 4205.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872616687116","ISSN":"2048-8734","issue":"2","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 28084079","page":"102-110","source":"PubMed","title":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score","title-short":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage)","volume":"7","author":[{"family":"Ishak","given":"Maycel"},{"family":"Ali","given":"Danish"},{"family":"Fokkert","given":"Marion J."},{"family":"Slingerland","given":"Robbert J."},{"family":"Tolsma","given":"Rudolf T."},{"family":"Badings","given":"Erik"},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Eenennaam","given":"Fred","non-dropping-particle":"van"},{"family":"Mosterd","given":"Arend"},{"family":"Ten Berg","given":"Jurri?n M."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"}],"issued":{"date-parts":[["2018",3]]}}},{"id":435,"uris":[""],"uri":[""],"itemData":{"id":435,"type":"article-journal","abstract":"BACKGROUND:: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE).\nMETHODS:: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ? 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death.\nRESULTS:: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%).\nCONCLUSIONS:: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872618813846","ISSN":"2048-8734","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 30468395","page":"2048872618813846","source":"PubMed","title":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study","title-short":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome","author":[{"family":"Dongen","given":"Dominique N.","non-dropping-particle":"van"},{"family":"Tolsma","given":"Rudolf T."},{"family":"Fokkert","given":"Marion J."},{"family":"Badings","given":"Erik A."},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Slingerland","given":"Robbert J."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"},{"family":"Ottervanger","given":"Jan Paul"}],"issued":{"date-parts":[["2018",11,23]]}}}],"schema":""} 16,35 used the HEART score as the clinical decision algorithm to aid in ACS risk stratification, with one study ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"dUX2AgJ5","properties":{"formattedCitation":"\\super 35\\nosupersub{}","plainCitation":"35","noteIndex":0},"citationItems":[{"id":439,"uris":[""],"uri":[""],"itemData":{"id":439,"type":"article-journal","abstract":"BACKGROUND: The first study of the FamouS Triage project investigates the feasibility of ruling out a myocardial infarction in pre-hospital chest pain patients without electrocardiographic ST-segment elevation by using the modified HEART score at the patient's home, incorporating only a single highly sensitive troponin T measurement.\nMETHODS: A venous blood sample was drawn in the ambulance from 1127 consecutive chest pain patients for measurement of the pre-hospital highly sensitive troponin T levels, in order to establish a pre-hospital HEART score (i.e. the modified HEART score) and evaluate the possibility of triage at the patient's home. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) i.e. acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or death within 30 days after initial presentation.\nRESULTS: Two hundred and six patients (18%) developed a MACE during 30 days of follow-up. Thirty-six per cent of the patients ( n=403) had a low modified HEART score (0-3 points) and none of them developed a MACE during follow-up. Forty-four per cent of the patients ( n=494) had an intermediate modified HEART score (4-6 points) and 18% of them developed a MACE. Twenty per cent of the patients ( n=230) had a high modified HEART score (7-10 points) of which 52% developed a MACE during follow-up.\nCONCLUSION: It seems feasible to rule out a myocardial infarction at home in chest pain patients without ST-segment elevation by using the modified HEART score.\nTRIAL ID: NTR4205. Dutch Trial Register [ ]: trial number 4205.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872616687116","ISSN":"2048-8734","issue":"2","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 28084079","page":"102-110","source":"PubMed","title":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score","title-short":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage)","volume":"7","author":[{"family":"Ishak","given":"Maycel"},{"family":"Ali","given":"Danish"},{"family":"Fokkert","given":"Marion J."},{"family":"Slingerland","given":"Robbert J."},{"family":"Tolsma","given":"Rudolf T."},{"family":"Badings","given":"Erik"},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Eenennaam","given":"Fred","non-dropping-particle":"van"},{"family":"Mosterd","given":"Arend"},{"family":"Ten Berg","given":"Jurri?n M."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"}],"issued":{"date-parts":[["2018",3]]}}}],"schema":""} 35 modifying the score with the use of a high-sensitivity troponin rather than the conventional fourth-generation troponin measurement. Although there was excellent sensitivity (100%) and negative predictive value (100%) for the modified HEART score algorithm, specificity (43%) and positive predictive value (29%) were less accurate. This could be due to the designation of intermediate and high values in the modified HEART scores as a ‘positive’ score in this review. When adjusting for only the high scores on the modified HEART algorithm then specificity increases to 87% and positive predictive value to 51%. As the authors acknowledge, the main objective of the HEART score is to rule-out rather than rule-in ACS, however, the risk stratification element could aid the rapid transfer of high-risk patients to specialist cardiac facilities ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"DuFJmZcF","properties":{"formattedCitation":"\\super 35\\nosupersub{}","plainCitation":"35","noteIndex":0},"citationItems":[{"id":439,"uris":[""],"uri":[""],"itemData":{"id":439,"type":"article-journal","abstract":"BACKGROUND: The first study of the FamouS Triage project investigates the feasibility of ruling out a myocardial infarction in pre-hospital chest pain patients without electrocardiographic ST-segment elevation by using the modified HEART score at the patient's home, incorporating only a single highly sensitive troponin T measurement.\nMETHODS: A venous blood sample was drawn in the ambulance from 1127 consecutive chest pain patients for measurement of the pre-hospital highly sensitive troponin T levels, in order to establish a pre-hospital HEART score (i.e. the modified HEART score) and evaluate the possibility of triage at the patient's home. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) i.e. acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or death within 30 days after initial presentation.\nRESULTS: Two hundred and six patients (18%) developed a MACE during 30 days of follow-up. Thirty-six per cent of the patients ( n=403) had a low modified HEART score (0-3 points) and none of them developed a MACE during follow-up. Forty-four per cent of the patients ( n=494) had an intermediate modified HEART score (4-6 points) and 18% of them developed a MACE. Twenty per cent of the patients ( n=230) had a high modified HEART score (7-10 points) of which 52% developed a MACE during follow-up.\nCONCLUSION: It seems feasible to rule out a myocardial infarction at home in chest pain patients without ST-segment elevation by using the modified HEART score.\nTRIAL ID: NTR4205. Dutch Trial Register [ ]: trial number 4205.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872616687116","ISSN":"2048-8734","issue":"2","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 28084079","page":"102-110","source":"PubMed","title":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score","title-short":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage)","volume":"7","author":[{"family":"Ishak","given":"Maycel"},{"family":"Ali","given":"Danish"},{"family":"Fokkert","given":"Marion J."},{"family":"Slingerland","given":"Robbert J."},{"family":"Tolsma","given":"Rudolf T."},{"family":"Badings","given":"Erik"},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Eenennaam","given":"Fred","non-dropping-particle":"van"},{"family":"Mosterd","given":"Arend"},{"family":"Ten Berg","given":"Jurri?n M."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"}],"issued":{"date-parts":[["2018",3]]}}}],"schema":""} 35. The greatest area for future development in CDSS is with computer-aided interpretation. Three of the CDSS in this review incorporated computer-integration for either ECG interpretation or for the final clinical decision ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"KbWIqOww","properties":{"formattedCitation":"\\super 20,30,34\\nosupersub{}","plainCitation":"20,30,34","noteIndex":0},"citationItems":[{"id":441,"uris":[""],"uri":[""],"itemData":{"id":441,"type":"article-journal","abstract":"BACKGROUND: To evaluate whether a computer-based decision support system could improve the allocation of patients with acute coronary syndrome (ACS) or a life-threatening condition (LTC). We hypothesised that a system of this kind would improve sensitivity without compromising specificity.\nMETHODS: A total of 2285 consecutive patients who dialed 112 due to chest pain were asked 10 specific questions and a prediction model was constructed based on the answers. We compared the sensitivity of the dispatchers' decisions with that of the model-based decision support model.\nRESULTS: A total of 2048 patients answered all 10 questions. Among the 235 patients with ACS, 194 were allocated the highest prioritisation by dispatchers (sensitivity 82.6%) and 41 patients were given a lower prioritisation (17.4% false negatives). The allocation suggested by the model used the highest prioritisation in 212 of the patients with ACS (sensitivity of 90.2%), while 23 patients were underprioritised (9.8% false negatives). The results were similar when the two systems were compared with regard to LTC and 30-day mortality. This indicates that computer-based decision support could be used either for increasing sensitivity or for saving resources. Three questions proved to be most important in terms of predicting ACS/LTC, [1] the intensity of pain, [2] the localisation of pain and [3] a history of ACS.\nCONCLUSION: Among patients with acute chest pain, computer-based decision support with a model based on a few fundamental questions could improve sensitivity and reduce the number of cases with the highest prioritisation without endangering the patients.","container-title":"International Journal of Cardiology","DOI":"10.1016/j.ijcard.2016.06.281","ISSN":"1874-1754","journalAbbreviation":"Int. J. Cardiol.","language":"eng","note":"PMID: 27393857","page":"734-738","source":"PubMed","title":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support? A cohort of patients with chest pain","title-short":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support?","volume":"220","author":[{"family":"Gellerstedt","given":"Martin"},{"family":"Rawshani","given":"Nina"},{"family":"Herlitz","given":"Johan"},{"family":"B?ng","given":"Angela"},{"family":"Gelang","given":"Carita"},{"family":"Andersson","given":"Jan-Otto"},{"family":"Larsson","given":"Anna"},{"family":"Rawshani","given":"Araz"}],"issued":{"date-parts":[["2016",10,1]]}}},{"id":220,"uris":[""],"uri":[""],"itemData":{"id":220,"type":"article-journal","abstract":"OBJECTIVE: ST-elevation myocardial infarction (STEMI) identification by emergency medicine services (EMS) leading to pre-hospital catheterization laboratory (CL) activation shortens ischemic time and improves outcomes. We examined the incremental value of addition of a screening clinical tool (CT), containing clinical information and a Zoll electrocardiogram (ECG)-resident STEMI identification program (ZI) to ZI alone.\nMETHODS: All EMS-performed and ZI-analyzed ECGs transmitted to a percutaneous coronary intervention hospital from October 2009 to January 2011 were reviewed for diagnostic accuracy. ZI performance was also compared to ECG interpretations by 2 experienced readers The CT was then retrospectively applied to determine the incremental benefit above the ZI alone.\nRESULTS: ST-elevation myocardial infarction was confirmed in 23 (7.5%) of 305 patients. ZI was positive in 37 (12.1%): sensitivity: 95.6% and specificity: 94.6%, positive predictive value (PPV), 59.5%, negative predictive value (NPV), 99.6%, and accuracy of 93.8%. Moderate agreement was observed among the readers and ZI. CT criteria for CL activation were met in 24 (7.8%): 20 (83.3%) were confirmed STEMIs: sensitivity: 86.9%, specificity: 98.5%, a PPV: 83.3%, and NPV: 98.6%, accuracy of 97.7%. CT + ZI increased PPV (P<0.05) and specificity (P<0.003) by reducing false positive STEMI identifications from 15 (4.9%) to 4 (1.3%).\nCONCLUSIONS: In an urban cohort of all EMS transmitted ECGs, ZI has high sensitivity and specificity for STEMI identification. Whereas the PPV was low, reflecting both low STEMI prevalence and presence of STEMI-mimics, the NPV was very high. These findings suggest that a simplified CT combined with computer STEMI interpretation can identify patients for pre-hospital CL activation. Confirmation of these results could improve the design of STEMI care systems.","container-title":"The American Journal of Emergency Medicine","DOI":"10.1016/j.ajem.2013.04.013","ISSN":"1532-8171","issue":"7","journalAbbreviation":"Am J Emerg Med","language":"eng","note":"PMID: 23706572","page":"1098-1102","source":"PubMed","title":"An algorithm for identification of ST-elevation myocardial infarction patients by emergency medicine services","volume":"31","author":[{"family":"Wilson","given":"Ryan E."},{"family":"Kado","given":"Herman S."},{"family":"Percy","given":"Robert F."},{"family":"Butterfield","given":"Ryan C."},{"family":"Sabato","given":"Joseph"},{"family":"Strom","given":"Joel A."},{"family":"Box","given":"Lyndon C."}],"issued":{"date-parts":[["2013",7]]}}},{"id":445,"uris":[""],"uri":[""],"itemData":{"id":445,"type":"article-journal","abstract":"BACKGROUND: Identifying ST-segment elevation myocardial infarctions (STEMIs) in the field can decrease door-to-balloon times. Paramedics may use a computer algorithm to help them interpret prehospital electrocariograms (ECGs). It is unknown how accurately the computer can identify STEMIs.\nOBJECTIVES: To Determine the sensitivity and specificity of prehospital ECGs in identifying patients with STEMI.\nMETHODS: Retrospective cross-sectional study of 200 prehospital ECGs acquired using Lifepak 12 monitors and transmitted by one of more than 20 emergency medical services (EMS) agencies to the emergency department (ED) of a Summa Akron City Hospital, a level 1 trauma center between January 1, 2007, and February 18, 2010. The ED sees more than 73,000 adult patients and treats 120 STEMIs annually. The laboratory performs 3,400 catheterizations annually. The first 100 patients with a diagnosis of STEMI and cardiac catheterization laboratory activation from the ED were analyzed. For comparison, a control group of 100 other ECGs from patients without a STEMI were randomly selected from our Medtronic database using a random-number generator. For patients with STEMI, an accurate computer interpretation was \"acute MI suspected.\" Other interpretations were counted as misses. Specificity and sensitivity were calculated with confidence intervals (CIs). The sample size was determined a priori for a 95% CI of ±10%.\nRESULTS: Zero control patients were incorrectly labeled \"acute MI suspected.\" The specificity was 100% (100/100; 95% CI 0.96-1.0), whereas the sensitivity was 58% (58/100; 95% CI 0.48-0.67). This would have resulted in 42 missed cardiac catheterization laboratory activations, but zero inappropriate activations. The most common incorrect interpretation of STEMI ECGs by the computer was \"data quality prohibits interpretation,\" followed by \"abnormal ECG unconfirmed.\"\nCONCLUSIONS: Prehospital computer interpretation is not sensitive for STEMI identification and should not be used as a single method for prehospital activation of the cardiac catheterizing laboratory. Because of its high specificity, it may serve as an adjunct to interpretation.","container-title":"Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors","DOI":"10.3109/10903127.2012.722176","ISSN":"1545-0066","issue":"2","journalAbbreviation":"Prehosp Emerg Care","language":"eng","note":"PMID: 23066910","page":"211-216","source":"PubMed","title":"Prehospital electrocardiographic computer identification of ST-segment elevation myocardial infarction","volume":"17","author":[{"family":"Bhalla","given":"Mary Colleen"},{"family":"Mencl","given":"Francis"},{"family":"Gist","given":"Mikki Amber"},{"family":"Wilber","given":"Scott"},{"family":"Zalewski","given":"Jon"}],"issued":{"date-parts":[["2013",6]]}}}],"schema":""} 20,30,34. The accuracy of MI diagnosis is seen in the two studies that utilised computer-aided interpretation of ECG, with high specificity (100% and 99%) and positive predictive value (100% and 83%) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"783lYx3D","properties":{"formattedCitation":"\\super 20,34,44\\nosupersub{}","plainCitation":"20,34,44","noteIndex":0},"citationItems":[{"id":445,"uris":[""],"uri":[""],"itemData":{"id":445,"type":"article-journal","abstract":"BACKGROUND: Identifying ST-segment elevation myocardial infarctions (STEMIs) in the field can decrease door-to-balloon times. Paramedics may use a computer algorithm to help them interpret prehospital electrocariograms (ECGs). It is unknown how accurately the computer can identify STEMIs.\nOBJECTIVES: To Determine the sensitivity and specificity of prehospital ECGs in identifying patients with STEMI.\nMETHODS: Retrospective cross-sectional study of 200 prehospital ECGs acquired using Lifepak 12 monitors and transmitted by one of more than 20 emergency medical services (EMS) agencies to the emergency department (ED) of a Summa Akron City Hospital, a level 1 trauma center between January 1, 2007, and February 18, 2010. The ED sees more than 73,000 adult patients and treats 120 STEMIs annually. The laboratory performs 3,400 catheterizations annually. The first 100 patients with a diagnosis of STEMI and cardiac catheterization laboratory activation from the ED were analyzed. For comparison, a control group of 100 other ECGs from patients without a STEMI were randomly selected from our Medtronic database using a random-number generator. For patients with STEMI, an accurate computer interpretation was \"acute MI suspected.\" Other interpretations were counted as misses. Specificity and sensitivity were calculated with confidence intervals (CIs). The sample size was determined a priori for a 95% CI of ±10%.\nRESULTS: Zero control patients were incorrectly labeled \"acute MI suspected.\" The specificity was 100% (100/100; 95% CI 0.96-1.0), whereas the sensitivity was 58% (58/100; 95% CI 0.48-0.67). This would have resulted in 42 missed cardiac catheterization laboratory activations, but zero inappropriate activations. The most common incorrect interpretation of STEMI ECGs by the computer was \"data quality prohibits interpretation,\" followed by \"abnormal ECG unconfirmed.\"\nCONCLUSIONS: Prehospital computer interpretation is not sensitive for STEMI identification and should not be used as a single method for prehospital activation of the cardiac catheterizing laboratory. Because of its high specificity, it may serve as an adjunct to interpretation.","container-title":"Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors","DOI":"10.3109/10903127.2012.722176","ISSN":"1545-0066","issue":"2","journalAbbreviation":"Prehosp Emerg Care","language":"eng","note":"PMID: 23066910","page":"211-216","source":"PubMed","title":"Prehospital electrocardiographic computer identification of ST-segment elevation myocardial infarction","volume":"17","author":[{"family":"Bhalla","given":"Mary Colleen"},{"family":"Mencl","given":"Francis"},{"family":"Gist","given":"Mikki Amber"},{"family":"Wilber","given":"Scott"},{"family":"Zalewski","given":"Jon"}],"issued":{"date-parts":[["2013",6]]}}},{"id":220,"uris":[""],"uri":[""],"itemData":{"id":220,"type":"article-journal","abstract":"OBJECTIVE: ST-elevation myocardial infarction (STEMI) identification by emergency medicine services (EMS) leading to pre-hospital catheterization laboratory (CL) activation shortens ischemic time and improves outcomes. We examined the incremental value of addition of a screening clinical tool (CT), containing clinical information and a Zoll electrocardiogram (ECG)-resident STEMI identification program (ZI) to ZI alone.\nMETHODS: All EMS-performed and ZI-analyzed ECGs transmitted to a percutaneous coronary intervention hospital from October 2009 to January 2011 were reviewed for diagnostic accuracy. ZI performance was also compared to ECG interpretations by 2 experienced readers The CT was then retrospectively applied to determine the incremental benefit above the ZI alone.\nRESULTS: ST-elevation myocardial infarction was confirmed in 23 (7.5%) of 305 patients. ZI was positive in 37 (12.1%): sensitivity: 95.6% and specificity: 94.6%, positive predictive value (PPV), 59.5%, negative predictive value (NPV), 99.6%, and accuracy of 93.8%. Moderate agreement was observed among the readers and ZI. CT criteria for CL activation were met in 24 (7.8%): 20 (83.3%) were confirmed STEMIs: sensitivity: 86.9%, specificity: 98.5%, a PPV: 83.3%, and NPV: 98.6%, accuracy of 97.7%. CT + ZI increased PPV (P<0.05) and specificity (P<0.003) by reducing false positive STEMI identifications from 15 (4.9%) to 4 (1.3%).\nCONCLUSIONS: In an urban cohort of all EMS transmitted ECGs, ZI has high sensitivity and specificity for STEMI identification. Whereas the PPV was low, reflecting both low STEMI prevalence and presence of STEMI-mimics, the NPV was very high. These findings suggest that a simplified CT combined with computer STEMI interpretation can identify patients for pre-hospital CL activation. Confirmation of these results could improve the design of STEMI care systems.","container-title":"The American Journal of Emergency Medicine","DOI":"10.1016/j.ajem.2013.04.013","ISSN":"1532-8171","issue":"7","journalAbbreviation":"Am J Emerg Med","language":"eng","note":"PMID: 23706572","page":"1098-1102","source":"PubMed","title":"An algorithm for identification of ST-elevation myocardial infarction patients by emergency medicine services","volume":"31","author":[{"family":"Wilson","given":"Ryan E."},{"family":"Kado","given":"Herman S."},{"family":"Percy","given":"Robert F."},{"family":"Butterfield","given":"Ryan C."},{"family":"Sabato","given":"Joseph"},{"family":"Strom","given":"Joel A."},{"family":"Box","given":"Lyndon C."}],"issued":{"date-parts":[["2013",7]]}}},{"id":706,"uris":[""],"uri":[""],"itemData":{"id":706,"type":"article-journal","abstract":"OBJECTIVE: To assess the validity of three different computerized electrocardiogram (ECG) interpretation algorithms in correctly identifying STEMI patients in the prehospital environment who require emergent cardiac intervention.\nMETHODS: This retrospective study validated three diagnostic algorithms (AG) against the presence of a culprit coronary artery upon cardiac catheterization. Two patient groups were enrolled in this study: those with verified prehospital ST-elevation myocardial infarction (STEMI) activation (cases) and those with a prehospital impression of chest pain due to ACS (controls).\nRESULTS: There were 500 records analyzed resulting in a case group with 151 patients and a control group with 349 patients. Sensitivities differed between AGs (AG1=0.69 vs AG2=0.68 vs AG3=0.62), with statistical differences in sensitivity found when comparing AG1 to AG3 and AG1 to AG2. Specificities also differed between AGs (AG1=0.89 vs AG2=0.91 vs AG3=0.95), with AG1 and AG2 significantly less specific than AG3.\nCONCLUSIONS: STEMI diagnostic algorithms vary in regards to their validity in identifying patients with culprit artery lesions. This suggests that systems could apply more sensitive or specific algorithms depending on the needs in their community.","container-title":"Journal of Electrocardiology","DOI":"10.1016/j.jelectrocard.2016.04.010","ISSN":"1532-8430","issue":"5","journalAbbreviation":"J Electrocardiol","language":"eng","note":"PMID: 27181187\nPMCID: PMC5613667","page":"728-732","source":"PubMed","title":"Electrocardiographic diagnosis of ST segment elevation myocardial infarction: An evaluation of three automated interpretation algorithms","title-short":"Electrocardiographic diagnosis of ST segment elevation myocardial infarction","volume":"49","author":[{"family":"Garvey","given":"J. Lee"},{"family":"Zegre-Hemsey","given":"Jessica"},{"family":"Gregg","given":"Richard"},{"family":"Studnek","given":"Jonathan R."}],"issued":{"date-parts":[["2016",10]]}}}],"schema":""} 20,34,44. However, one study which looked only at the digital ECG for the decision support had lower sensitivity (58%) and negative predictive value (30%) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"E79HFXcW","properties":{"formattedCitation":"\\super 20\\nosupersub{}","plainCitation":"20","noteIndex":0},"citationItems":[{"id":445,"uris":[""],"uri":[""],"itemData":{"id":445,"type":"article-journal","abstract":"BACKGROUND: Identifying ST-segment elevation myocardial infarctions (STEMIs) in the field can decrease door-to-balloon times. Paramedics may use a computer algorithm to help them interpret prehospital electrocariograms (ECGs). It is unknown how accurately the computer can identify STEMIs.\nOBJECTIVES: To Determine the sensitivity and specificity of prehospital ECGs in identifying patients with STEMI.\nMETHODS: Retrospective cross-sectional study of 200 prehospital ECGs acquired using Lifepak 12 monitors and transmitted by one of more than 20 emergency medical services (EMS) agencies to the emergency department (ED) of a Summa Akron City Hospital, a level 1 trauma center between January 1, 2007, and February 18, 2010. The ED sees more than 73,000 adult patients and treats 120 STEMIs annually. The laboratory performs 3,400 catheterizations annually. The first 100 patients with a diagnosis of STEMI and cardiac catheterization laboratory activation from the ED were analyzed. For comparison, a control group of 100 other ECGs from patients without a STEMI were randomly selected from our Medtronic database using a random-number generator. For patients with STEMI, an accurate computer interpretation was \"acute MI suspected.\" Other interpretations were counted as misses. Specificity and sensitivity were calculated with confidence intervals (CIs). The sample size was determined a priori for a 95% CI of ±10%.\nRESULTS: Zero control patients were incorrectly labeled \"acute MI suspected.\" The specificity was 100% (100/100; 95% CI 0.96-1.0), whereas the sensitivity was 58% (58/100; 95% CI 0.48-0.67). This would have resulted in 42 missed cardiac catheterization laboratory activations, but zero inappropriate activations. The most common incorrect interpretation of STEMI ECGs by the computer was \"data quality prohibits interpretation,\" followed by \"abnormal ECG unconfirmed.\"\nCONCLUSIONS: Prehospital computer interpretation is not sensitive for STEMI identification and should not be used as a single method for prehospital activation of the cardiac catheterizing laboratory. Because of its high specificity, it may serve as an adjunct to interpretation.","container-title":"Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors","DOI":"10.3109/10903127.2012.722176","ISSN":"1545-0066","issue":"2","journalAbbreviation":"Prehosp Emerg Care","language":"eng","note":"PMID: 23066910","page":"211-216","source":"PubMed","title":"Prehospital electrocardiographic computer identification of ST-segment elevation myocardial infarction","volume":"17","author":[{"family":"Bhalla","given":"Mary Colleen"},{"family":"Mencl","given":"Francis"},{"family":"Gist","given":"Mikki Amber"},{"family":"Wilber","given":"Scott"},{"family":"Zalewski","given":"Jon"}],"issued":{"date-parts":[["2013",6]]}}}],"schema":""} 20. The use of computer-aided decision making is a rapidly-developing field with advances in radiology and pathology especially ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"bQpUMjj4","properties":{"formattedCitation":"\\super 45\\nosupersub{}","plainCitation":"45","noteIndex":0},"citationItems":[{"id":470,"uris":[""],"uri":[""],"itemData":{"id":470,"type":"article-journal","abstract":"Computer-aided detection and diagnosis (CAD) systems are increasingly being used as an aid by clinicians for detection and interpretation of diseases. Computer-aided detection systems mark regions of an image that may reveal specific abnormalities and are used to alert clinicians to these regions during image interpretation. Computer-aided diagnosis systems provide an assessment of a disease using image-based information alone or in combination with other relevant diagnostic data and are used by clinicians as a decision support in developing their diagnoses. While CAD systems are commercially available, standardized approaches for evaluating and reporting their performance have not yet been fully formalized in the literature or in a standardization effort. This deficiency has led to difficulty in the comparison of CAD devices and in understanding how the reported performance might translate into clinical practice. To address these important issues, the American Association of Physicists in Medicine (AAPM) formed the Computer Aided Detection in Diagnostic Imaging Subcommittee (CADSC), in part, to develop recommendations on approaches for assessing CAD system performance. The purpose of this paper is to convey the opinions of the AAPM CADSC members and to stimulate the development of consensus approaches and “best practices” for evaluating CAD systems. Both the assessment of a standalone CAD system and the evaluation of the impact of CAD on end-users are discussed. It is hoped that awareness of these important evaluation elements and the CADSC recommendations will lead to further development of structured guidelines for CAD performance assessment. Proper assessment of CAD system performance is expected to increase the understanding of a CAD system's effectiveness and limitations, which is expected to stimulate further research and development efforts on CAD technologies, reduce problems due to improper use, and eventually improve the utility and efficacy of CAD in clinical practice.","container-title":"Medical Physics","DOI":"10.1118/1.4816310","ISSN":"0094-2405","issue":"8","journalAbbreviation":"Med Phys","note":"PMID: 23927365\nPMCID: PMC4108682","source":"PubMed Central","title":"Evaluation of computer-aided detection and diagnosis systems","URL":"","volume":"40","author":[{"family":"Petrick","given":"Nicholas"},{"family":"Sahiner","given":"Berkman"},{"family":"Armato","given":"Samuel G."},{"family":"Bert","given":"Alberto"},{"family":"Correale","given":"Loredana"},{"family":"Delsanto","given":"Silvia"},{"family":"Freedman","given":"Matthew T."},{"family":"Fryd","given":"David"},{"family":"Gur","given":"David"},{"family":"Hadjiiski","given":"Lubomir"},{"family":"Huo","given":"Zhimin"},{"family":"Jiang","given":"Yulei"},{"family":"Morra","given":"Lia"},{"family":"Paquerault","given":"Sophie"},{"family":"Raykar","given":"Vikas"},{"family":"Samuelson","given":"Frank"},{"family":"Summers","given":"Ronald M."},{"family":"Tourassi","given":"Georgia"},{"family":"Yoshida","given":"Hiroyuki"},{"family":"Zheng","given":"Bin"},{"family":"Zhou","given":"Chuan"},{"family":"Chan","given":"Heang-Ping"}],"accessed":{"date-parts":[["2019",2,8]]},"issued":{"date-parts":[["2013",8]]}}}],"schema":""} 45. However, the role of computer-aided decision making in ECG interpretation has been previously reported with varying sensitivity and specificity ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"zef3Hnbl","properties":{"formattedCitation":"\\super 46,47\\nosupersub{}","plainCitation":"46,47","noteIndex":0},"citationItems":[{"id":473,"uris":[""],"uri":[""],"itemData":{"id":473,"type":"article-journal","abstract":"The aims of this study were to assess the effectiveness of 2 automated electrocardiogram interpretation programs in patients with suspected acute coronary syndrome transported to hospital by ambulance in 1 rural region of Denmark with hospital discharge diagnosis used as the gold standard and to assess the effectiveness of cardiologists' triage decisions for these patients based on initial electrocardiogram. Twelve-lead electrocardiograms were recorded in ambulances using a LIFEPAK 12 monitor/defibrillator (Physio-Control, Inc., Redmond, Washington) and transmitted digitally to an attending cardiologist. If a diagnosis of ST elevation myocardial infarction was made, a patient was taken to a regional interventional center for primary percutaneous coronary intervention or to a local hospital. One thousand consecutive digital electrocardiograms and corresponding interpretations from LIFEPAK 12 were available, and these were subsequently interpreted by the University of Glasgow program. Electrocardiogram interpretations and cardiologists' decisions were compared to hospital discharge diagnoses. The sensitivity, specificity, and positive predictive values for a report of ST elevation myocardial infarction with respect to discharge diagnosis were 78%, 91%, and 81% for LIFEPAK 12 and 78%, 94%, and 87% for the Glasgow program. Corresponding data for attending cardiologists were 85%, 90%, and 81%. In conclusion, the Glasgow program had significantly higher specificity than the LIFEPAK 12 program (p = 0.02) and the cardiologists (p = 0.004). Triage decisions were effective, with good agreement between cardiologists' decisions and discharge diagnoses.","container-title":"The American Journal of Cardiology","DOI":"10.1016/j.amjcard.2010.07.047","ISSN":"1879-1913","issue":"12","journalAbbreviation":"Am. J. Cardiol.","language":"eng","note":"PMID: 21126612","page":"1696-1702","source":"PubMed","title":"Automated electrocardiogram interpretation programs versus cardiologists' triage decision making based on teletransmitted data in patients with suspected acute coronary syndrome","volume":"106","author":[{"family":"Clark","given":"Elaine N."},{"family":"Sejersten","given":"Maria"},{"family":"Clemmensen","given":"Peter"},{"family":"Macfarlane","given":"Peter W."}],"issued":{"date-parts":[["2010",12,15]]}}},{"id":480,"uris":[""],"uri":[""],"itemData":{"id":480,"type":"article-journal","abstract":"OBJECTIVES: Most studies of pre-hospital management of ST-elevation myocardial infarction (STEMI) have involved physicians accompanying the ambulance crew, or electrocardiogram (ECG) transmission to a physician at the base hospital. We sought to determine if Advanced Care Paramedics (ACPs) could accurately identify STEMI on the pre-hospital ECG and contribute to strategies that shorten time to reperfusion.\nMETHODS: A STEMI tool was developed to: 1) measure the accuracy of the ACPs at diagnosing STEMI; and 2) determine the potential time saved if ACPs were to independently administer thrombolytic therapy. Using registry data, we subsequently estimated the time saved by initiating thrombolytic therapy in the field compared with in-hospital administration by a physician.\nRESULTS: Between August 2003 and July 2004, a correct diagnosis of STEMI on the pre-hospital ECG was confirmed in 63 patients. The performance of the ACPs in identifying STEMI on the ECG resulted in a sensitivity of 95% (95% confidence interval [CI] 86%-99%), a specificity of 96% (95% CI 94%-98%), a positive predictive value (PPV) of 82% (95% CI 71%-90%), and a negative predictive value (NPV) of 99% (95% CI 97%-100%). ACP performance for appropriately using thrombolytic therapy resulted in a sensitivity of 92% (95% CI 78%-98%), a specificity of 97% (95% CI 94%-98%), a PPV of 73% (95% CI 59%-85%) and an NPV of 99% (95% CI 97%-100%). We estimated that the median time saved by ACP administration of thrombolytic therapy would have been 44 minutes.\nCONCLUSIONS: ACPs can be trained to accurately interpret the pre-hospital ECG for the diagnosis of STEMI. These results are important for the design of regional integrated programs aimed at reducing delays to reperfusion.","container-title":"CJEM","ISSN":"1481-8035","issue":"6","journalAbbreviation":"CJEM","language":"eng","note":"PMID: 17209489","page":"401-407","source":"PubMed","title":"Diagnostic performance and potential clinical impact of advanced care paramedic interpretation of ST-segment elevation myocardial infarction in the field","volume":"8","author":[{"family":"Le May","given":"Michel R."},{"family":"Dionne","given":"Richard"},{"family":"Maloney","given":"Justin"},{"family":"Trickett","given":"John"},{"family":"Watpool","given":"Irene"},{"family":"Ruest","given":"Michel"},{"family":"Stiell","given":"Ian"},{"family":"Ryan","given":"Sheila"},{"family":"Davies","given":"Richard F."}],"issued":{"date-parts":[["2006",11]]}}}],"schema":""} 46,47. Deep learning techniques for ECG interpretation have enormous potential to improve ECG ACS detection with the ability to detect subtle signs of ischaemia and continually learn from their findings ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"xf0gTPCs","properties":{"formattedCitation":"\\super 48\\nosupersub{}","plainCitation":"48","noteIndex":0},"citationItems":[{"id":709,"uris":[""],"uri":[""],"itemData":{"id":709,"type":"article-journal","abstract":"Patients with suspected acute coronary syndrome (ACS) are at risk of transient myocardial ischemia (TMI), which could lead to serious morbidity or even mortality. Early detection of myocardial ischemia can reduce damage to heart tissues and improve patient condition. Significant ST change in the electrocardiogram (ECG) is an important marker for detecting myocardial ischemia during the rule-out phase of potential ACS. However, current ECG monitoring software is vastly underused due to excessive false alarms. The present study aims to tackle this problem by combining a novel image-based approach with deep learning techniques to improve the detection accuracy of significant ST depression change. The obtained convolutional neural network (CNN) model yields an average area under the curve (AUC) at 89.6% from an independent testing set. At selected optimal cutoff thresholds, the proposed model yields a mean sensitivity at 84.4% while maintaining specificity at 84.9%.","container-title":"AMIA Summits on Translational Science Proceedings","ISSN":"2153-4063","journalAbbreviation":"AMIA Jt Summits Transl Sci Proc","note":"PMID: 29888083\nPMCID: PMC5961830","page":"256-262","source":"PubMed Central","title":"A Deep Learning Approach to Examine Ischemic ST Changes in Ambulatory ECG Recordings","volume":"2018","author":[{"family":"Xiao","given":"Ran"},{"family":"Xu","given":"Yuan"},{"family":"Pelter","given":"Michele M."},{"family":"Mortara","given":"David W."},{"family":"Hu","given":"Xiao"}],"issued":{"date-parts":[["2018",5,18]]}}}],"schema":""} 48. Computer aided decision making was not only limited to ECG interpretation. One study looked at the use of a computer-aided decision system for medical dispatch to patients presenting with chest pain, with the only component being patient history, and it found good sensitivity (92%) and negative predictive value (97%) but poor specificity (41%) and positive predictive value (17%) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"fPXBtaEv","properties":{"formattedCitation":"\\super 30\\nosupersub{}","plainCitation":"30","noteIndex":0},"citationItems":[{"id":441,"uris":[""],"uri":[""],"itemData":{"id":441,"type":"article-journal","abstract":"BACKGROUND: To evaluate whether a computer-based decision support system could improve the allocation of patients with acute coronary syndrome (ACS) or a life-threatening condition (LTC). We hypothesised that a system of this kind would improve sensitivity without compromising specificity.\nMETHODS: A total of 2285 consecutive patients who dialed 112 due to chest pain were asked 10 specific questions and a prediction model was constructed based on the answers. We compared the sensitivity of the dispatchers' decisions with that of the model-based decision support model.\nRESULTS: A total of 2048 patients answered all 10 questions. Among the 235 patients with ACS, 194 were allocated the highest prioritisation by dispatchers (sensitivity 82.6%) and 41 patients were given a lower prioritisation (17.4% false negatives). The allocation suggested by the model used the highest prioritisation in 212 of the patients with ACS (sensitivity of 90.2%), while 23 patients were underprioritised (9.8% false negatives). The results were similar when the two systems were compared with regard to LTC and 30-day mortality. This indicates that computer-based decision support could be used either for increasing sensitivity or for saving resources. Three questions proved to be most important in terms of predicting ACS/LTC, [1] the intensity of pain, [2] the localisation of pain and [3] a history of ACS.\nCONCLUSION: Among patients with acute chest pain, computer-based decision support with a model based on a few fundamental questions could improve sensitivity and reduce the number of cases with the highest prioritisation without endangering the patients.","container-title":"International Journal of Cardiology","DOI":"10.1016/j.ijcard.2016.06.281","ISSN":"1874-1754","journalAbbreviation":"Int. J. Cardiol.","language":"eng","note":"PMID: 27393857","page":"734-738","source":"PubMed","title":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support? A cohort of patients with chest pain","title-short":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support?","volume":"220","author":[{"family":"Gellerstedt","given":"Martin"},{"family":"Rawshani","given":"Nina"},{"family":"Herlitz","given":"Johan"},{"family":"B?ng","given":"Angela"},{"family":"Gelang","given":"Carita"},{"family":"Andersson","given":"Jan-Otto"},{"family":"Larsson","given":"Anna"},{"family":"Rawshani","given":"Araz"}],"issued":{"date-parts":[["2016",10,1]]}}}],"schema":""} 30. The use of a computer-aided decision system can help assimilate a large amount of data when assessing a patient and help prioritise patients dependent on certain features in the history and risk-factors. Innovations in computerised ACS diagnosis highlight the potential of machine learning where constant refinement of the algorithm accuracy can produce increasingly accurate decisions ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Jlh36jCe","properties":{"formattedCitation":"\\super 39\\nosupersub{}","plainCitation":"39","noteIndex":0},"citationItems":[{"id":713,"uris":[""],"uri":[""],"itemData":{"id":713,"type":"article-journal","abstract":"BACKGROUND: Variations in cardiac troponin concentrations by age, sex and time between samples in patients with suspected myocardial infarction are not currently accounted for in diagnostic approaches. We aimed to combine these variables through machine learning to improve the assessment of risk for individual patients.\nMETHODS: A machine learning algorithm (myocardial-ischemic-injury-index [MI3]) incorporating age, sex, and paired high-sensitivity cardiac troponin I concentrations, was trained on 3,013 patients and tested on 7,998 patients with suspected myocardial infarction. MI3 uses gradient boosting to compute a value (0-100) reflecting an individual's likelihood of a diagnosis of type 1 myocardial infarction and estimates the sensitivity, negative predictive value (NPV), specificity and positive predictive value (PPV) for that individual. Assessment was by calibration and area under the receiver-operating-characteristic curve (AUC). Secondary analysis evaluated example MI3 thresholds from the training set that identified patients as low-risk (99% sensitivity) and high-risk (75% PPV), and performance at these thresholds was compared in the test set to the 99th percentile and European Society of Cardiology (ESC) rule-out pathways.\nRESULTS: Myocardial infarction occurred in 404 (13.4%) patients in the training set and 849 (10.6%) patients in the test set. MI3 was well calibrated with a very high AUC of 0.963 [0.956-0.971] in the test set and similar performance in early and late presenters. Example MI3 thresholds identifying low-risk and high-risk patients in the training set were 1.6 and 49.7 respectively. In the test set, MI3 values were <1.6 in 69.5% with a NPV of 99.7% (99.5%-99.8%) and sensitivity of 97.8% (96.7-98.7%), and were ≥49.7 in 10.6% with a PPV of 71.8% (68.9-75.0%) and specificity of 96.7% (96.3-97.1%). Using these thresholds, MI3 performed better than the ESC 0/3-hour pathway (sensitivity 82.5% [74.5-88.8%], specificity 92.2% [90.7-93.5%]) and the 99th percentile at any time-point (sensitivity 89.6% [87.4-91.6%]), specificity 89.3% [88.6-90.0%]).\nCONCLUSIONS: Using machine learning, MI3 provides an individualized and objective assessment of the likelihood of myocardial infarction, which can be used to identify low-risk and high-risk patients who may benefit from earlier clinical decisions.\nCLINICAL TRIAL REGISTRATION: Unique Identifier: Australian New Zealand Clinical Trials Registry: ACTRN12616001441404. URL: .","container-title":"Circulation","DOI":"10.1161/CIRCULATIONAHA.119.041980","ISSN":"1524-4539","journalAbbreviation":"Circulation","language":"eng","note":"PMID: 31416346\nPMCID: PMC6749969","source":"PubMed","title":"Machine Learning to Predict the Likelihood of Acute Myocardial Infarction","author":[{"family":"Than","given":"Martin P."},{"family":"Pickering","given":"John W."},{"family":"Sandoval","given":"Yader"},{"family":"Shah","given":"Anoop S. V."},{"family":"Tsanas","given":"Athanasios"},{"family":"Apple","given":"Fred S."},{"family":"Blankenberg","given":"Stefan"},{"family":"Cullen","given":"Louise"},{"family":"Mueller","given":"Christian"},{"family":"Neumann","given":"Johannes T."},{"family":"Twerenbold","given":"Raphael"},{"family":"Westermann","given":"Dirk"},{"family":"Beshiri","given":"Agim"},{"family":"Mills","given":"Nicholas L."},{"literal":"MI3 collaborative"}],"issued":{"date-parts":[["2019",8,16]]}}}],"schema":""} 39. This use of computer-aided decision systems in the pre-hospital setting can be advantageous, where often there is no experienced cardiologist present and paramedic crews, with limited training, may have to interpret the clinical situation and ECG alone ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"E7dk0RnF","properties":{"formattedCitation":"\\super 47\\nosupersub{}","plainCitation":"47","noteIndex":0},"citationItems":[{"id":480,"uris":[""],"uri":[""],"itemData":{"id":480,"type":"article-journal","abstract":"OBJECTIVES: Most studies of pre-hospital management of ST-elevation myocardial infarction (STEMI) have involved physicians accompanying the ambulance crew, or electrocardiogram (ECG) transmission to a physician at the base hospital. We sought to determine if Advanced Care Paramedics (ACPs) could accurately identify STEMI on the pre-hospital ECG and contribute to strategies that shorten time to reperfusion.\nMETHODS: A STEMI tool was developed to: 1) measure the accuracy of the ACPs at diagnosing STEMI; and 2) determine the potential time saved if ACPs were to independently administer thrombolytic therapy. Using registry data, we subsequently estimated the time saved by initiating thrombolytic therapy in the field compared with in-hospital administration by a physician.\nRESULTS: Between August 2003 and July 2004, a correct diagnosis of STEMI on the pre-hospital ECG was confirmed in 63 patients. The performance of the ACPs in identifying STEMI on the ECG resulted in a sensitivity of 95% (95% confidence interval [CI] 86%-99%), a specificity of 96% (95% CI 94%-98%), a positive predictive value (PPV) of 82% (95% CI 71%-90%), and a negative predictive value (NPV) of 99% (95% CI 97%-100%). ACP performance for appropriately using thrombolytic therapy resulted in a sensitivity of 92% (95% CI 78%-98%), a specificity of 97% (95% CI 94%-98%), a PPV of 73% (95% CI 59%-85%) and an NPV of 99% (95% CI 97%-100%). We estimated that the median time saved by ACP administration of thrombolytic therapy would have been 44 minutes.\nCONCLUSIONS: ACPs can be trained to accurately interpret the pre-hospital ECG for the diagnosis of STEMI. These results are important for the design of regional integrated programs aimed at reducing delays to reperfusion.","container-title":"CJEM","ISSN":"1481-8035","issue":"6","journalAbbreviation":"CJEM","language":"eng","note":"PMID: 17209489","page":"401-407","source":"PubMed","title":"Diagnostic performance and potential clinical impact of advanced care paramedic interpretation of ST-segment elevation myocardial infarction in the field","volume":"8","author":[{"family":"Le May","given":"Michel R."},{"family":"Dionne","given":"Richard"},{"family":"Maloney","given":"Justin"},{"family":"Trickett","given":"John"},{"family":"Watpool","given":"Irene"},{"family":"Ruest","given":"Michel"},{"family":"Stiell","given":"Ian"},{"family":"Ryan","given":"Sheila"},{"family":"Davies","given":"Richard F."}],"issued":{"date-parts":[["2006",11]]}}}],"schema":""} 47. The one study which had the computer ECG interpretation with combination of a clinical screening tool led to high sensitivity (86.9%) and specificity (98.5%) suggesting that an integrated approach with other components could be beneficial ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"7wELeY99","properties":{"formattedCitation":"\\super 34\\nosupersub{}","plainCitation":"34","noteIndex":0},"citationItems":[{"id":220,"uris":[""],"uri":[""],"itemData":{"id":220,"type":"article-journal","abstract":"OBJECTIVE: ST-elevation myocardial infarction (STEMI) identification by emergency medicine services (EMS) leading to pre-hospital catheterization laboratory (CL) activation shortens ischemic time and improves outcomes. We examined the incremental value of addition of a screening clinical tool (CT), containing clinical information and a Zoll electrocardiogram (ECG)-resident STEMI identification program (ZI) to ZI alone.\nMETHODS: All EMS-performed and ZI-analyzed ECGs transmitted to a percutaneous coronary intervention hospital from October 2009 to January 2011 were reviewed for diagnostic accuracy. ZI performance was also compared to ECG interpretations by 2 experienced readers The CT was then retrospectively applied to determine the incremental benefit above the ZI alone.\nRESULTS: ST-elevation myocardial infarction was confirmed in 23 (7.5%) of 305 patients. ZI was positive in 37 (12.1%): sensitivity: 95.6% and specificity: 94.6%, positive predictive value (PPV), 59.5%, negative predictive value (NPV), 99.6%, and accuracy of 93.8%. Moderate agreement was observed among the readers and ZI. CT criteria for CL activation were met in 24 (7.8%): 20 (83.3%) were confirmed STEMIs: sensitivity: 86.9%, specificity: 98.5%, a PPV: 83.3%, and NPV: 98.6%, accuracy of 97.7%. CT + ZI increased PPV (P<0.05) and specificity (P<0.003) by reducing false positive STEMI identifications from 15 (4.9%) to 4 (1.3%).\nCONCLUSIONS: In an urban cohort of all EMS transmitted ECGs, ZI has high sensitivity and specificity for STEMI identification. Whereas the PPV was low, reflecting both low STEMI prevalence and presence of STEMI-mimics, the NPV was very high. These findings suggest that a simplified CT combined with computer STEMI interpretation can identify patients for pre-hospital CL activation. Confirmation of these results could improve the design of STEMI care systems.","container-title":"The American Journal of Emergency Medicine","DOI":"10.1016/j.ajem.2013.04.013","ISSN":"1532-8171","issue":"7","journalAbbreviation":"Am J Emerg Med","language":"eng","note":"PMID: 23706572","page":"1098-1102","source":"PubMed","title":"An algorithm for identification of ST-elevation myocardial infarction patients by emergency medicine services","volume":"31","author":[{"family":"Wilson","given":"Ryan E."},{"family":"Kado","given":"Herman S."},{"family":"Percy","given":"Robert F."},{"family":"Butterfield","given":"Ryan C."},{"family":"Sabato","given":"Joseph"},{"family":"Strom","given":"Joel A."},{"family":"Box","given":"Lyndon C."}],"issued":{"date-parts":[["2013",7]]}}}],"schema":""} 34.LimitationsThere are several important limitations with this study. Due to the high volume of ACS research,?and in combination?with?the broad-search strategy, there is a possibility that some?literature has been missed. This search strategy was employed to aid the identification of studies that examined principle components, such as patient history within CDSS, before the adoption of new technologies, such as pre-hospital ECG and biomarkers. The considerable heterogeneity in CDSS which limited the statistical analyses that could be done, particularly with one study contributing 98% of the population for statistical analysis, hence the results must be taken with caution. In addition, MI was variously defined using the published universal definitions of MI ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"u8OAWTHs","properties":{"formattedCitation":"\\super 16,30,32,34,35\\nosupersub{}","plainCitation":"16,30,32,34,35","noteIndex":0},"citationItems":[{"id":441,"uris":[""],"uri":[""],"itemData":{"id":441,"type":"article-journal","abstract":"BACKGROUND: To evaluate whether a computer-based decision support system could improve the allocation of patients with acute coronary syndrome (ACS) or a life-threatening condition (LTC). We hypothesised that a system of this kind would improve sensitivity without compromising specificity.\nMETHODS: A total of 2285 consecutive patients who dialed 112 due to chest pain were asked 10 specific questions and a prediction model was constructed based on the answers. We compared the sensitivity of the dispatchers' decisions with that of the model-based decision support model.\nRESULTS: A total of 2048 patients answered all 10 questions. Among the 235 patients with ACS, 194 were allocated the highest prioritisation by dispatchers (sensitivity 82.6%) and 41 patients were given a lower prioritisation (17.4% false negatives). The allocation suggested by the model used the highest prioritisation in 212 of the patients with ACS (sensitivity of 90.2%), while 23 patients were underprioritised (9.8% false negatives). The results were similar when the two systems were compared with regard to LTC and 30-day mortality. This indicates that computer-based decision support could be used either for increasing sensitivity or for saving resources. Three questions proved to be most important in terms of predicting ACS/LTC, [1] the intensity of pain, [2] the localisation of pain and [3] a history of ACS.\nCONCLUSION: Among patients with acute chest pain, computer-based decision support with a model based on a few fundamental questions could improve sensitivity and reduce the number of cases with the highest prioritisation without endangering the patients.","container-title":"International Journal of Cardiology","DOI":"10.1016/j.ijcard.2016.06.281","ISSN":"1874-1754","journalAbbreviation":"Int. J. Cardiol.","language":"eng","note":"PMID: 27393857","page":"734-738","source":"PubMed","title":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support? A cohort of patients with chest pain","title-short":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support?","volume":"220","author":[{"family":"Gellerstedt","given":"Martin"},{"family":"Rawshani","given":"Nina"},{"family":"Herlitz","given":"Johan"},{"family":"B?ng","given":"Angela"},{"family":"Gelang","given":"Carita"},{"family":"Andersson","given":"Jan-Otto"},{"family":"Larsson","given":"Anna"},{"family":"Rawshani","given":"Araz"}],"issued":{"date-parts":[["2016",10,1]]}}},{"id":220,"uris":[""],"uri":[""],"itemData":{"id":220,"type":"article-journal","abstract":"OBJECTIVE: ST-elevation myocardial infarction (STEMI) identification by emergency medicine services (EMS) leading to pre-hospital catheterization laboratory (CL) activation shortens ischemic time and improves outcomes. We examined the incremental value of addition of a screening clinical tool (CT), containing clinical information and a Zoll electrocardiogram (ECG)-resident STEMI identification program (ZI) to ZI alone.\nMETHODS: All EMS-performed and ZI-analyzed ECGs transmitted to a percutaneous coronary intervention hospital from October 2009 to January 2011 were reviewed for diagnostic accuracy. ZI performance was also compared to ECG interpretations by 2 experienced readers The CT was then retrospectively applied to determine the incremental benefit above the ZI alone.\nRESULTS: ST-elevation myocardial infarction was confirmed in 23 (7.5%) of 305 patients. ZI was positive in 37 (12.1%): sensitivity: 95.6% and specificity: 94.6%, positive predictive value (PPV), 59.5%, negative predictive value (NPV), 99.6%, and accuracy of 93.8%. Moderate agreement was observed among the readers and ZI. CT criteria for CL activation were met in 24 (7.8%): 20 (83.3%) were confirmed STEMIs: sensitivity: 86.9%, specificity: 98.5%, a PPV: 83.3%, and NPV: 98.6%, accuracy of 97.7%. CT + ZI increased PPV (P<0.05) and specificity (P<0.003) by reducing false positive STEMI identifications from 15 (4.9%) to 4 (1.3%).\nCONCLUSIONS: In an urban cohort of all EMS transmitted ECGs, ZI has high sensitivity and specificity for STEMI identification. Whereas the PPV was low, reflecting both low STEMI prevalence and presence of STEMI-mimics, the NPV was very high. These findings suggest that a simplified CT combined with computer STEMI interpretation can identify patients for pre-hospital CL activation. Confirmation of these results could improve the design of STEMI care systems.","container-title":"The American Journal of Emergency Medicine","DOI":"10.1016/j.ajem.2013.04.013","ISSN":"1532-8171","issue":"7","journalAbbreviation":"Am J Emerg Med","language":"eng","note":"PMID: 23706572","page":"1098-1102","source":"PubMed","title":"An algorithm for identification of ST-elevation myocardial infarction patients by emergency medicine services","volume":"31","author":[{"family":"Wilson","given":"Ryan E."},{"family":"Kado","given":"Herman S."},{"family":"Percy","given":"Robert F."},{"family":"Butterfield","given":"Ryan C."},{"family":"Sabato","given":"Joseph"},{"family":"Strom","given":"Joel A."},{"family":"Box","given":"Lyndon C."}],"issued":{"date-parts":[["2013",7]]}}},{"id":439,"uris":[""],"uri":[""],"itemData":{"id":439,"type":"article-journal","abstract":"BACKGROUND: The first study of the FamouS Triage project investigates the feasibility of ruling out a myocardial infarction in pre-hospital chest pain patients without electrocardiographic ST-segment elevation by using the modified HEART score at the patient's home, incorporating only a single highly sensitive troponin T measurement.\nMETHODS: A venous blood sample was drawn in the ambulance from 1127 consecutive chest pain patients for measurement of the pre-hospital highly sensitive troponin T levels, in order to establish a pre-hospital HEART score (i.e. the modified HEART score) and evaluate the possibility of triage at the patient's home. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) i.e. acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or death within 30 days after initial presentation.\nRESULTS: Two hundred and six patients (18%) developed a MACE during 30 days of follow-up. Thirty-six per cent of the patients ( n=403) had a low modified HEART score (0-3 points) and none of them developed a MACE during follow-up. Forty-four per cent of the patients ( n=494) had an intermediate modified HEART score (4-6 points) and 18% of them developed a MACE. Twenty per cent of the patients ( n=230) had a high modified HEART score (7-10 points) of which 52% developed a MACE during follow-up.\nCONCLUSION: It seems feasible to rule out a myocardial infarction at home in chest pain patients without ST-segment elevation by using the modified HEART score.\nTRIAL ID: NTR4205. Dutch Trial Register [ ]: trial number 4205.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872616687116","ISSN":"2048-8734","issue":"2","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 28084079","page":"102-110","source":"PubMed","title":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score","title-short":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage)","volume":"7","author":[{"family":"Ishak","given":"Maycel"},{"family":"Ali","given":"Danish"},{"family":"Fokkert","given":"Marion J."},{"family":"Slingerland","given":"Robbert J."},{"family":"Tolsma","given":"Rudolf T."},{"family":"Badings","given":"Erik"},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Eenennaam","given":"Fred","non-dropping-particle":"van"},{"family":"Mosterd","given":"Arend"},{"family":"Ten Berg","given":"Jurri?n M."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"}],"issued":{"date-parts":[["2018",3]]}}},{"id":447,"uris":[""],"uri":[""],"itemData":{"id":447,"type":"article-journal","abstract":"BACKGROUND: Diagnosing acute coronary syndrome (ACS) in a primary care setting poses a diagnostic dilemma for physicians.\nOBJECTIVE: We directly compared the diagnostic accuracy of a clinical decision rule (CDR) based on history taking and physical examination in suspected ACS with the risk estimates of the attending GP.\nMETHODS: In a prospective multicenter study, patients suspected of ACS were included by the GP. GPs were asked to estimate the probability (0%-100%) of the presence of ACS. GPs collected patient data, but they were not aware of the CDR and did not score the patient accordingly.\nRESULTS: Two hundred and ninety-eight patients were included (52% female, mean age 66 years, 22% ACS). The area under the receiver operating characteristic (ROC) curve (AUC) was 0.75 [95% confidence interval (CI) 0.68-0.82] for the GP risk estimate and 0.66 (95% CI 0.58-0.73) for the CDR. There was an agreement between the risk estimation of the GP and a CDR in 51% and the prevalence of ACS in predefined low-, intermediate- and high-risk groups was similar for the GP and CDR estimates. In the low-risk group, according to the GP, four patients (8.2%) suffered an ACS. These four patients were all identified by the decision rule as high risk.\nCONCLUSIONS: The GP classified patients as ACS or no ACS more adequately than the CDR, judged by the AUC. However, the use of a CDR in patients that are considered at low risk for ACS by the GP could reduce the amount of missed myocardial infarctions.","container-title":"Family Practice","DOI":"10.1093/fampra/cmq116","ISSN":"1460-2229","issue":"3","journalAbbreviation":"Fam Pract","language":"eng","note":"PMID: 21239470","page":"323-328","source":"PubMed","title":"Diagnosing acute coronary syndrome in primary care: comparison of the physicians' risk estimation and a clinical decision rule","title-short":"Diagnosing acute coronary syndrome in primary care","volume":"28","author":[{"family":"Bruins Slot","given":"M. H. E."},{"family":"Rutten","given":"F. H."},{"family":"Heijden","given":"G. J. M. G.","non-dropping-particle":"van der"},{"family":"Geersing","given":"G. J."},{"family":"Glatz","given":"J. F. C."},{"family":"Hoes","given":"A. W."}],"issued":{"date-parts":[["2011",6]]}}},{"id":435,"uris":[""],"uri":[""],"itemData":{"id":435,"type":"article-journal","abstract":"BACKGROUND:: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE).\nMETHODS:: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ? 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death.\nRESULTS:: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%).\nCONCLUSIONS:: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.","container-title":"European Heart Journal. Acute Cardiovascular Care","DOI":"10.1177/2048872618813846","ISSN":"2048-8734","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","note":"PMID: 30468395","page":"2048872618813846","source":"PubMed","title":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study","title-short":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome","author":[{"family":"Dongen","given":"Dominique N.","non-dropping-particle":"van"},{"family":"Tolsma","given":"Rudolf T."},{"family":"Fokkert","given":"Marion J."},{"family":"Badings","given":"Erik A."},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Slingerland","given":"Robbert J."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"},{"family":"Ottervanger","given":"Jan Paul"}],"issued":{"date-parts":[["2018",11,23]]}}}],"schema":""} 16,30,32,34,35, a combination of an ECG and biomarker criteria ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"TDT7WfyH","properties":{"formattedCitation":"\\super 31,33\\nosupersub{}","plainCitation":"31,33","noteIndex":0},"citationItems":[{"id":437,"uris":[""],"uri":[""],"itemData":{"id":437,"type":"article-journal","abstract":"BACKGROUND: The purposes of this study were to create a new flow-chart of prehospital electrocardiography (ECG)-transmission, evaluate its predictive ability for ST-elevation myocardial infarction (STEMI) and shorten door-to-balloon time (DTBT).\nMETHOD AND RESULTS: The new transmission flow-chart was created using symptoms from previous medical records of STEMI patients. A total of 4090 consecutive patients transferred emergently to our hospital were divided into two groups: those in ambulances with an ECG-transmission device with the new flow-chart (ECGT-FC) and those transferred without an ECG-transmission device (non-ECGT) groups. A STEMI group comprising walk-in patients during the same period was used as a control group. The predictive ability of STEMI and the effectiveness of shortening the DTBT by the new flow-chart of ECG-transmission was evaluated. In the ECGT-FC group, the prevalence of STEMI in the ECG-transmission by the new flow-chart were significantly higher than in the non-ECG-transmission patients (6.71% vs. 0.19%; p<0.001). The sensitivity and specificity of the new ECG-transmission flow-chart were 83.3% and 88.1%, respectively. The median DTBT was significantly shortened (p=0.045) and the prevalence of DTBT<90min was significantly higher in the ECGT-FC group (p=0.018) than the other groups.\nCONCLUSION: The sensitivity and specificity of the new flow-chart for ECG-transmission were high. The new flow-chart combined with an ECG-transmission device could detect STEMI efficiently and shorten DTBT.","container-title":"Journal of Cardiology","DOI":"10.1016/j.jjcc.2018.03.011","ISSN":"1876-4738","issue":"4","journalAbbreviation":"J Cardiol","language":"eng","note":"PMID: 29804908","page":"335-342","source":"PubMed","title":"Predictive ability and efficacy for shortening door-to-balloon time of a new prehospital electrocardiogram-transmission flow chart in patients with ST-elevation myocardial infarction - Results of the CASSIOPEIA study","volume":"72","author":[{"family":"Sakai","given":"Toshiaki"},{"family":"Nishiyama","given":"Osamu"},{"family":"Onodera","given":"Masayuki"},{"family":"Matsuda","given":"Shigekatsu"},{"family":"Wakisawa","given":"Shinobu"},{"family":"Nakamura","given":"Motoyuki"},{"family":"Morino","given":"Yoshihiro"},{"family":"Itoh","given":"Tomonori"},{"literal":"CASSIOPEIA study group"}],"issued":{"date-parts":[["2018",10]]}}},{"id":478,"uris":[""],"uri":[""],"itemData":{"id":478,"type":"article-journal","abstract":"OBJECTIVE: To improve pre-hospital triage of patients with suspected acute cardiac disease.\nDESIGN: Prospective study. SUBJECTS. Patients with symptoms suggestive of acute cardiac pathology, who were seen by a general practitioner, for whom acute admission into hospital was requested, and in whom a pre-hospital electrocardiogram was recorded by the ambulance service.\nMETHODS: The study consisted of two phases. In the first phase, a decision rule was developed based on clinical characteristics and electrocardiographic findings in 1005 patients with suspected acute cardiac pathology. In the second phase, the decision rule was prospectively validated. Symptoms were recorded by a standardized questionnaire by the general practitioner and a computerized electrocardiogram was made by the ambulance nurses at the patient's home. Three electrocardiographic outcomes were available: 'normal electrocardiogram', 'possible myocardial infarction' or 'extensive myocardial infarction'. By use of the predictive model, the general practitioner could decide if hospitalization was necessary or not.\nMAIN OUTCOME MEASUREMENTS: Identification of patients at low (stable angina, atypical chest pain, other pathology) and high (myocardial infarction, unstable angina) probability of acute cardiac pathology.\nRESULTS: Among 977 patients with a complete pre-hospital evaluation in the validation phase of the study, the decision rule recommended 'no hospitalization' in 227 patients (23%). The general practitioner followed this advice in 44% of these patients. Although seven of them developed a non-Q wave myocardial infarction, no complications occurred in patients not admitted. In addition, the general practitioner did not hospitalize 19 (2%) of 750 patients for whom the decision rule recommended admission. Pre-hospital triage by the general practitioner resulted in a 12% (118 of 977 patients) reduction of the number of patients admitted to the Coronary Care Units.\nCONCLUSIONS: Pre-hospital triage by the general practitioner was facilitated using a standardized questionnaire and pre-hospital electrocardiography, and resulted in a reduction in the number of patients admitted to the Coronary Care Unit, and proved to be safe.","container-title":"European Heart Journal","ISSN":"0195-668X","issue":"1","journalAbbreviation":"Eur. Heart J.","language":"eng","note":"PMID: 8682136","page":"89-95","source":"PubMed","title":"Implementation of a pre-hospital decision rule in general practice. Triage of patients with suspected myocardial infarction","volume":"17","author":[{"family":"Grijseels","given":"E. W."},{"family":"Deckers","given":"J. W."},{"family":"Hoes","given":"A. W."},{"family":"Boersma","given":"E."},{"family":"Hartman","given":"J. A."},{"family":"Does","given":"E.","non-dropping-particle":"van der"},{"family":"Simoons","given":"M. L."}],"issued":{"date-parts":[["1996",1]]}}}],"schema":""} 31,33 or by ECG alone ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"4S6j9Uv8","properties":{"formattedCitation":"\\super 20\\nosupersub{}","plainCitation":"20","noteIndex":0},"citationItems":[{"id":445,"uris":[""],"uri":[""],"itemData":{"id":445,"type":"article-journal","abstract":"BACKGROUND: Identifying ST-segment elevation myocardial infarctions (STEMIs) in the field can decrease door-to-balloon times. Paramedics may use a computer algorithm to help them interpret prehospital electrocariograms (ECGs). It is unknown how accurately the computer can identify STEMIs.\nOBJECTIVES: To Determine the sensitivity and specificity of prehospital ECGs in identifying patients with STEMI.\nMETHODS: Retrospective cross-sectional study of 200 prehospital ECGs acquired using Lifepak 12 monitors and transmitted by one of more than 20 emergency medical services (EMS) agencies to the emergency department (ED) of a Summa Akron City Hospital, a level 1 trauma center between January 1, 2007, and February 18, 2010. The ED sees more than 73,000 adult patients and treats 120 STEMIs annually. The laboratory performs 3,400 catheterizations annually. The first 100 patients with a diagnosis of STEMI and cardiac catheterization laboratory activation from the ED were analyzed. For comparison, a control group of 100 other ECGs from patients without a STEMI were randomly selected from our Medtronic database using a random-number generator. For patients with STEMI, an accurate computer interpretation was \"acute MI suspected.\" Other interpretations were counted as misses. Specificity and sensitivity were calculated with confidence intervals (CIs). The sample size was determined a priori for a 95% CI of ±10%.\nRESULTS: Zero control patients were incorrectly labeled \"acute MI suspected.\" The specificity was 100% (100/100; 95% CI 0.96-1.0), whereas the sensitivity was 58% (58/100; 95% CI 0.48-0.67). This would have resulted in 42 missed cardiac catheterization laboratory activations, but zero inappropriate activations. The most common incorrect interpretation of STEMI ECGs by the computer was \"data quality prohibits interpretation,\" followed by \"abnormal ECG unconfirmed.\"\nCONCLUSIONS: Prehospital computer interpretation is not sensitive for STEMI identification and should not be used as a single method for prehospital activation of the cardiac catheterizing laboratory. Because of its high specificity, it may serve as an adjunct to interpretation.","container-title":"Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors","DOI":"10.3109/10903127.2012.722176","ISSN":"1545-0066","issue":"2","journalAbbreviation":"Prehosp Emerg Care","language":"eng","note":"PMID: 23066910","page":"211-216","source":"PubMed","title":"Prehospital electrocardiographic computer identification of ST-segment elevation myocardial infarction","volume":"17","author":[{"family":"Bhalla","given":"Mary Colleen"},{"family":"Mencl","given":"Francis"},{"family":"Gist","given":"Mikki Amber"},{"family":"Wilber","given":"Scott"},{"family":"Zalewski","given":"Jon"}],"issued":{"date-parts":[["2013",6]]}}}],"schema":""} 20. There was a notable variation in the incidence of ACS, ranging from 0.02% ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"YQg8DLRT","properties":{"formattedCitation":"\\super 31\\nosupersub{}","plainCitation":"31","noteIndex":0},"citationItems":[{"id":437,"uris":[""],"uri":[""],"itemData":{"id":437,"type":"article-journal","abstract":"BACKGROUND: The purposes of this study were to create a new flow-chart of prehospital electrocardiography (ECG)-transmission, evaluate its predictive ability for ST-elevation myocardial infarction (STEMI) and shorten door-to-balloon time (DTBT).\nMETHOD AND RESULTS: The new transmission flow-chart was created using symptoms from previous medical records of STEMI patients. A total of 4090 consecutive patients transferred emergently to our hospital were divided into two groups: those in ambulances with an ECG-transmission device with the new flow-chart (ECGT-FC) and those transferred without an ECG-transmission device (non-ECGT) groups. A STEMI group comprising walk-in patients during the same period was used as a control group. The predictive ability of STEMI and the effectiveness of shortening the DTBT by the new flow-chart of ECG-transmission was evaluated. In the ECGT-FC group, the prevalence of STEMI in the ECG-transmission by the new flow-chart were significantly higher than in the non-ECG-transmission patients (6.71% vs. 0.19%; p<0.001). The sensitivity and specificity of the new ECG-transmission flow-chart were 83.3% and 88.1%, respectively. The median DTBT was significantly shortened (p=0.045) and the prevalence of DTBT<90min was significantly higher in the ECGT-FC group (p=0.018) than the other groups.\nCONCLUSION: The sensitivity and specificity of the new flow-chart for ECG-transmission were high. The new flow-chart combined with an ECG-transmission device could detect STEMI efficiently and shorten DTBT.","container-title":"Journal of Cardiology","DOI":"10.1016/j.jjcc.2018.03.011","ISSN":"1876-4738","issue":"4","journalAbbreviation":"J Cardiol","language":"eng","note":"PMID: 29804908","page":"335-342","source":"PubMed","title":"Predictive ability and efficacy for shortening door-to-balloon time of a new prehospital electrocardiogram-transmission flow chart in patients with ST-elevation myocardial infarction - Results of the CASSIOPEIA study","volume":"72","author":[{"family":"Sakai","given":"Toshiaki"},{"family":"Nishiyama","given":"Osamu"},{"family":"Onodera","given":"Masayuki"},{"family":"Matsuda","given":"Shigekatsu"},{"family":"Wakisawa","given":"Shinobu"},{"family":"Nakamura","given":"Motoyuki"},{"family":"Morino","given":"Yoshihiro"},{"family":"Itoh","given":"Tomonori"},{"literal":"CASSIOPEIA study group"}],"issued":{"date-parts":[["2018",10]]}}}],"schema":""} 31 to 50% ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"mO0t4d1m","properties":{"formattedCitation":"\\super 20\\nosupersub{}","plainCitation":"20","noteIndex":0},"citationItems":[{"id":445,"uris":[""],"uri":[""],"itemData":{"id":445,"type":"article-journal","abstract":"BACKGROUND: Identifying ST-segment elevation myocardial infarctions (STEMIs) in the field can decrease door-to-balloon times. Paramedics may use a computer algorithm to help them interpret prehospital electrocariograms (ECGs). It is unknown how accurately the computer can identify STEMIs.\nOBJECTIVES: To Determine the sensitivity and specificity of prehospital ECGs in identifying patients with STEMI.\nMETHODS: Retrospective cross-sectional study of 200 prehospital ECGs acquired using Lifepak 12 monitors and transmitted by one of more than 20 emergency medical services (EMS) agencies to the emergency department (ED) of a Summa Akron City Hospital, a level 1 trauma center between January 1, 2007, and February 18, 2010. The ED sees more than 73,000 adult patients and treats 120 STEMIs annually. The laboratory performs 3,400 catheterizations annually. The first 100 patients with a diagnosis of STEMI and cardiac catheterization laboratory activation from the ED were analyzed. For comparison, a control group of 100 other ECGs from patients without a STEMI were randomly selected from our Medtronic database using a random-number generator. For patients with STEMI, an accurate computer interpretation was \"acute MI suspected.\" Other interpretations were counted as misses. Specificity and sensitivity were calculated with confidence intervals (CIs). The sample size was determined a priori for a 95% CI of ±10%.\nRESULTS: Zero control patients were incorrectly labeled \"acute MI suspected.\" The specificity was 100% (100/100; 95% CI 0.96-1.0), whereas the sensitivity was 58% (58/100; 95% CI 0.48-0.67). This would have resulted in 42 missed cardiac catheterization laboratory activations, but zero inappropriate activations. The most common incorrect interpretation of STEMI ECGs by the computer was \"data quality prohibits interpretation,\" followed by \"abnormal ECG unconfirmed.\"\nCONCLUSIONS: Prehospital computer interpretation is not sensitive for STEMI identification and should not be used as a single method for prehospital activation of the cardiac catheterizing laboratory. Because of its high specificity, it may serve as an adjunct to interpretation.","container-title":"Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors","DOI":"10.3109/10903127.2012.722176","ISSN":"1545-0066","issue":"2","journalAbbreviation":"Prehosp Emerg Care","language":"eng","note":"PMID: 23066910","page":"211-216","source":"PubMed","title":"Prehospital electrocardiographic computer identification of ST-segment elevation myocardial infarction","volume":"17","author":[{"family":"Bhalla","given":"Mary Colleen"},{"family":"Mencl","given":"Francis"},{"family":"Gist","given":"Mikki Amber"},{"family":"Wilber","given":"Scott"},{"family":"Zalewski","given":"Jon"}],"issued":{"date-parts":[["2013",6]]}}}],"schema":""} 20. This was due to patient selection for analysis, with the first study having included all patients presenting to emergency services (n=347,989), whereas the second study focussed exclusively on pre-hospital transmitted ECGs suspected of STEMI (n=200) and therefore targeted a select patient group with a higher incidence of ACS. Despite this, the review was able to document the nature and extent of the heterogeneity of the studies, including the components of CDSS and the methods used to examine them. It also provided the opportunity to examine what components were important in the pre-hospital diagnosis of ACS, and to compare the value of individual components and combinations thereof. Further researchFurther research would be useful to assess the accuracy of the high sensitivity of CDSS involving multiple components combined with the high specificity of computer-aided decision systems. CDSS research requires further validation in different clinical environments before CDSS are deployed for widespread use. In addition, impact analysis also helps judge whether the beneficial effects of CDSS would remain once fully incorporated into clinical use. Other effects that CDSS have on users need to be explored, including automation bias where the clinician can over-trust the decision aid ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"eeLtQOx2","properties":{"formattedCitation":"\\super 49\\nosupersub{}","plainCitation":"49","noteIndex":0},"citationItems":[{"id":543,"uris":[""],"uri":[""],"itemData":{"id":543,"type":"article-journal","abstract":"INTRODUCTION: Interpretation of the 12?lead Electrocardiogram (ECG) is normally assisted with an automated diagnosis (AD), which can facilitate an 'automation bias' where interpreters can be anchored. In this paper, we studied, 1) the effect of an incorrect AD on interpretation accuracy and interpreter confidence (a proxy for uncertainty), and 2) whether confidence and other interpreter features can predict interpretation accuracy using machine learning.\nMETHODS: This study analysed 9000 ECG interpretations from cardiology and non-cardiology fellows (CFs and non-CFs). One third of the ECGs involved no ADs, one third with ADs (half as incorrect) and one third had multiple ADs. Interpretations were scored and interpreter confidence was recorded for each interpretation and subsequently standardised using sigma scaling. Spearman coefficients were used for correlation analysis and C5.0 decision trees were used for predicting interpretation accuracy using basic interpreter features such as confidence, age, experience and designation.\nRESULTS: Interpretation accuracies achieved by CFs and non-CFs dropped by 43.20% and 58.95% respectively when an incorrect AD was presented (p?<?0.001). Overall correlation between scaled confidence and interpretation accuracy was higher amongst CFs. However, correlation between confidence and interpretation accuracy decreased for both groups when an incorrect AD was presented. We found that an incorrect AD disturbs the reliability of interpreter confidence in predicting accuracy. An incorrect AD has a greater effect on the confidence of non-CFs (although this is not statistically significant it is close to the threshold, p?=?0.065). The best C5.0 decision tree achieved an accuracy rate of 64.67% (p?<?0.001), however this is only 6.56% greater than the no-information-rate.\nCONCLUSION: Incorrect ADs reduce the interpreter's diagnostic accuracy indicating an automation bias. Non-CFs tend to agree more with the ADs in comparison to CFs, hence less expert physicians are more effected by automation bias. Incorrect ADs reduce the interpreter's confidence and also reduces the predictive power of confidence for predicting accuracy (even more so for non-CFs). Whilst a statistically significant model was developed, it is difficult to predict interpretation accuracy using machine learning on basic features such as interpreter confidence, age, reader experience and designation.","container-title":"Journal of Electrocardiology","DOI":"10.1016/j.jelectrocard.2018.08.007","ISSN":"1532-8430","issue":"6S","journalAbbreviation":"J Electrocardiol","language":"eng","note":"PMID: 30122457","page":"S6-S11","source":"PubMed","title":"Automation bias in medicine: The influence of automated diagnoses on interpreter accuracy and uncertainty when reading electrocardiograms","title-short":"Automation bias in medicine","volume":"51","author":[{"family":"Bond","given":"Raymond R."},{"family":"Novotny","given":"Tomas"},{"family":"Andrsova","given":"Irena"},{"family":"Koc","given":"Lumir"},{"family":"Sisakova","given":"Martina"},{"family":"Finlay","given":"Dewar"},{"family":"Guldenring","given":"Daniel"},{"family":"McLaughlin","given":"James"},{"family":"Peace","given":"Aaron"},{"family":"McGilligan","given":"Victoria"},{"family":"Leslie","given":"Stephen J."},{"family":"Wang","given":"Hui"},{"family":"Malik","given":"Marek"}],"issued":{"date-parts":[["2018",12]]}}}],"schema":""} 49. The user interface design of CDSS is another area that needs further research. Human factors and interaction design guidelines are often ignored in designing CDSS ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"pRUn0QTo","properties":{"formattedCitation":"\\super 50\\nosupersub{}","plainCitation":"50","noteIndex":0},"citationItems":[{"id":694,"uris":[""],"uri":[""],"itemData":{"id":694,"type":"article-journal","abstract":"BACKGROUND: Advanced Computerized Decision Support Systems (CDSSs) assist clinicians in their decision-making process, generating recommendations based on up-to-date scientific evidence. Although this technology has the potential to improve the quality of patient care, its mere provision does not guarantee uptake: even where CDSSs are available, clinicians often fail to adopt their recommendations. This study examines the barriers and facilitators to the uptake of an evidence-based CDSS as perceived by diverse health professionals in hospitals at different stages of CDSS adoption.\nMETHODS: Qualitative study conducted as part of a series of randomized controlled trials of CDSSs. The sample includes two hospitals using a CDSS and two hospitals that aim to adopt a CDSS in the future. We interviewed physicians, nurses, information technology staff, and members of the boards of directors (n?=?30). We used a constant comparative approach to develop a framework for guiding implementation.\nRESULTS: We identified six clusters of experiences of, and attitudes towards CDSSs, which we label as \"positions.\" The six positions represent a gradient of acquisition of control over CDSSs (from low to high) and are characterized by different types of barriers to CDSS uptake. The most severe barriers (prevalent in the first positions) include clinicians' perception that the CDSSs may reduce their professional autonomy or may be used against them in the event of medical-legal controversies. Moving towards the last positions, these barriers are substituted by technical and usability problems related to the technology interface. When all barriers are overcome, CDSSs are perceived as a working tool at the service of its users, integrating clinicians' reasoning and fostering organizational learning.\nCONCLUSIONS: Barriers and facilitators to the use of CDSSs are dynamic and may exist prior to their introduction in clinical contexts; providing a static list of obstacles and facilitators, irrespective of the specific implementation phase and context, may not be sufficient or useful to facilitate uptake. Factors such as clinicians' attitudes towards scientific evidences and guidelines, the quality of inter-disciplinary relationships, and an organizational ethos of transparency and accountability need to be considered when exploring the readiness of a hospital to adopt CDSSs.","container-title":"Implementation science: IS","DOI":"10.1186/s13012-017-0644-2","ISSN":"1748-5908","issue":"1","journalAbbreviation":"Implement Sci","language":"eng","note":"PMID: 28915822\nPMCID: PMC5602839","page":"113","source":"PubMed","title":"What hinders the uptake of computerized decision support systems in hospitals? A qualitative study and framework for implementation","title-short":"What hinders the uptake of computerized decision support systems in hospitals?","volume":"12","author":[{"family":"Liberati","given":"Elisa G."},{"family":"Ruggiero","given":"Francesca"},{"family":"Galuppo","given":"Laura"},{"family":"Gorli","given":"Mara"},{"family":"González-Lorenzo","given":"Marien"},{"family":"Maraldi","given":"Marco"},{"family":"Ruggieri","given":"Pietro"},{"family":"Polo Friz","given":"Hernan"},{"family":"Scaratti","given":"Giuseppe"},{"family":"Kwag","given":"Koren H."},{"family":"Vespignani","given":"Roberto"},{"family":"Moja","given":"Lorenzo"}],"issued":{"date-parts":[["2017"]],"season":"15"}}}],"schema":""} 50. However, one study used human-computer interaction design principles to design CDSS to aid ECG interpretation ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"wRUlAa4K","properties":{"formattedCitation":"\\super 51\\nosupersub{}","plainCitation":"51","noteIndex":0},"citationItems":[{"id":549,"uris":[""],"uri":[""],"itemData":{"id":549,"type":"article-journal","abstract":"INTRODUCTION: The 12-lead Electrocardiogram (ECG) presents a plethora of information and demands extensive knowledge and a high cognitive workload to interpret. Whilst the ECG is an important clinical tool, it is frequently incorrectly interpreted. Even expert clinicians are known to impulsively provide a diagnosis based on their first impression and often miss co-abnormalities. Given it is widely reported that there is a lack of competency in ECG interpretation, it is imperative to optimise the interpretation process. Predominantly the ECG interpretation process remains a paper based approach and whilst computer algorithms are used to assist interpreters by providing printed computerised diagnoses, there are a lack of interactive human-computer interfaces to guide and assist the interpreter.\nMETHODS: An interactive computing system was developed to guide the decision making process of a clinician when interpreting the ECG. The system decomposes the interpretation process into a series of interactive sub-tasks and encourages the clinician to systematically interpret the ECG. We have named this model 'Interactive Progressive based Interpretation' (IPI) as the user cannot 'progress' unless they complete each sub-task. Using this model, the ECG is segmented into five parts and presented over five user interfaces (1: Rhythm interpretation, 2: Interpretation of the P-wave morphology, 3: Limb lead interpretation, 4: QRS morphology interpretation with chest lead and rhythm strip presentation and 5: Final review of 12-lead ECG). The IPI model was implemented using emerging web technologies (i.e. HTML5, CSS3, AJAX, PHP and MySQL). It was hypothesised that this system would reduce the number of interpretation errors and increase diagnostic accuracy in ECG interpreters. To test this, we compared the diagnostic accuracy of clinicians when they used the standard approach (control cohort) with clinicians who interpreted the same ECGs using the IPI approach (IPI cohort).\nRESULTS: For the control cohort, the (mean; standard deviation; confidence interval) of the ECG interpretation accuracy was (45.45%; SD=18.1%; CI=42.07, 48.83). The mean ECG interpretation accuracy rate for the IPI cohort was 58.85% (SD=42.4%; CI=49.12, 68.58), which indicates a positive mean difference of 13.4%. (CI=4.45, 22.35) An N-1 Chi-square test of independence indicated a 92% chance that the IPI cohort will have a higher accuracy rate. Interpreter self-rated confidence also increased between cohorts from a mean of 4.9/10 in the control cohort to 6.8/10 in the IPI cohort (p=0.06). Whilst the IPI cohort had greater diagnostic accuracy, the duration of ECG interpretation was six times longer when compared to the control cohort.\nCONCLUSIONS: We have developed a system that segments and presents the ECG across five graphical user interfaces. Results indicate that this approach improves diagnostic accuracy but with the expense of time, which is a valuable resource in medical practice.","container-title":"Journal of Biomedical Informatics","DOI":"10.1016/j.jbi.2016.09.016","ISSN":"1532-0480","journalAbbreviation":"J Biomed Inform","language":"eng","note":"PMID: 27687552","page":"93-107","source":"PubMed","title":"A computer-human interaction model to improve the diagnostic accuracy and clinical decision-making during 12-lead electrocardiogram interpretation","volume":"64","author":[{"family":"Cairns","given":"Andrew W."},{"family":"Bond","given":"Raymond R."},{"family":"Finlay","given":"Dewar D."},{"family":"Breen","given":"Cathal"},{"family":"Guldenring","given":"Daniel"},{"family":"Gaffney","given":"Robert"},{"family":"Gallagher","given":"Anthony G."},{"family":"Peace","given":"Aaron J."},{"family":"Henn","given":"Pat"}],"issued":{"date-parts":[["2016"]]}}}],"schema":""} 51. They used eye tracking analysis of ECG interpretation ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Ecx6hSsH","properties":{"formattedCitation":"\\super 52\\nosupersub{}","plainCitation":"52","noteIndex":0},"citationItems":[{"id":553,"uris":[""],"uri":[""],"itemData":{"id":553,"type":"article-journal","abstract":"INTRODUCTION: It is well known that accurate interpretation of the 12-lead electrocardiogram (ECG) requires a high degree of skill. There is also a moderate degree of variability among those who interpret the ECG. While this is the case, there are no best practice guidelines for the actual ECG interpretation process. Hence, this study adopts computerized eye tracking technology to investigate whether eye-gaze can be used to gain a deeper insight into how expert annotators interpret the ECG. Annotators were recruited in San Jose, California at the 2013 International Society of Computerised Electrocardiology (ISCE).\nMETHODS: Each annotator was recruited to interpret a number of 12-lead ECGs (N=12) while their eye gaze was recorded using a Tobii X60 eye tracker. The device is based on corneal reflection and is non-intrusive. With a sampling rate of 60Hz, eye gaze coordinates were acquired every 16.7ms. Fixations were determined using a predefined computerized classification algorithm, which was then used to generate heat maps of where the annotators looked. The ECGs used in this study form four groups (3=ST elevation myocardial infarction [STEMI], 3=hypertrophy, 3=arrhythmias and 3=exhibiting unique artefacts). There was also an equal distribution of difficulty levels (3=easy to interpret, 3=average and 3=difficult). ECGs were displayed using the 4x3+1 display format and computerized annotations were concealed.\nRESULTS: Precisely 252 expert ECG interpretations (21 annotators×12 ECGs) were recorded. Average duration for ECG interpretation was 58s (SD=23). Fleiss' generalized kappa coefficient (Pa=0.56) indicated a moderate inter-rater reliability among the annotators. There was a 79% inter-rater agreement for STEMI cases, 71% agreement for arrhythmia cases, 65% for the lead misplacement and dextrocardia cases and only 37% agreement for the hypertrophy cases. In analyzing the total fixation duration, it was found that on average annotators study lead V1 the most (4.29s), followed by leads V2 (3.83s), the rhythm strip (3.47s), II (2.74s), V3 (2.63s), I (2.53s), aVL (2.45s), V5 (2.27s), aVF (1.74s), aVR (1.63s), V6 (1.39s), III (1.32s) and V4 (1.19s). It was also found that on average the annotator spends an equal amount of time studying leads in the frontal plane (15.89s) when compared to leads in the transverse plane (15.70s). It was found that on average the annotators fixated on lead I first followed by leads V2, aVL, V1, II, aVR, V3, rhythm strip, III, aVF, V5, V4 and V6. We found a strong correlation (r=0.67) between time to first fixation on a lead and the total fixation duration on each lead. This indicates that leads studied first are studied the longest. There was a weak negative correlation between duration and accuracy (r=-0.2) and a strong correlation between age and accuracy (r=0.67).\nCONCLUSIONS: Eye tracking facilitated a deeper insight into how expert annotators interpret the 12-lead ECG. As a result, the authors recommend ECG annotators to adopt an initial first impression/pattern recognition approach followed by a conventional systematic protocol to ECG interpretation. This recommendation is based on observing misdiagnoses given due to first impression only. In summary, this research presents eye gaze results from expert ECG annotators and provides scope for future work that involves exploiting computerized eye tracking technology to further the science of ECG interpretation.","container-title":"Journal of Electrocardiology","DOI":"10.1016/j.jelectrocard.2014.07.011","ISSN":"1532-8430","issue":"6","journalAbbreviation":"J Electrocardiol","language":"eng","note":"PMID: 25110276","page":"895-906","source":"PubMed","title":"Assessing computerized eye tracking technology for gaining insight into expert interpretation of the 12-lead electrocardiogram: an objective quantitative approach","title-short":"Assessing computerized eye tracking technology for gaining insight into expert interpretation of the 12-lead electrocardiogram","volume":"47","author":[{"family":"Bond","given":"R. R."},{"family":"Zhu","given":"T."},{"family":"Finlay","given":"D. D."},{"family":"Drew","given":"B."},{"family":"Kligfield","given":"P. D."},{"family":"Guldenring","given":"D."},{"family":"Breen","given":"C."},{"family":"Gallagher","given":"A. G."},{"family":"Daly","given":"M. J."},{"family":"Clifford","given":"G. D."}],"issued":{"date-parts":[["2014",12]]}}}],"schema":""} 52 and their understanding of human cognition and working memory to breakdown the ECG interpretation process into manageable tasks on CDSS to eventually present multiple automated diagnoses in order to prevent automation bias and to encourage differential decision making. Whilst CDSS are mostly concerned with the provision of algorithmic text-based suggestions, future work may also involve better use of intelligent dynamic graphics as part of the algorithmic output for depicting more spatiotemporal data to augment the decision support ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"BGNEFQIZ","properties":{"formattedCitation":"\\super 53\\nosupersub{}","plainCitation":"53","noteIndex":0},"citationItems":[{"id":557,"uris":[""],"uri":[""],"itemData":{"id":557,"type":"article-journal","abstract":"INTRODUCTION: The electrocardiogram (ECG) is a recording of the electrical activity of the heart. It is commonly used to non-invasively assess the cardiac activity of a patient. Since 1938, ECG data has been visualised as 12 scalar traces (known as the standard 12-lead ECG). Although this is known as the standard approach, there has been a myriad of alternative methods proposed to visualise ECG data. The purpose of this paper is to provide an overview of these methods and to introduce the field of ECG visualisation to early stage researchers. A scientific purpose is to consider the future of ECG visualisation within routine clinical practice.\nMETHODS: This paper structures the different ECG visualisation methods using four categories, i.e. temporal, vectorial, spatial and interactive. Temporal methods present the data with respect to time, vectorial methods present data with respect to direction and magnitude, spatial methods present data in 2D or 3D space and interactive methods utilise interactive computing to facilitate efficient interrogation of ECG data at different levels of detail.\nCONCLUSION: Spatial visualisation has been around since its introduction by Waller and vector based visualisation has been around since the 1920s. Given these approaches have already been given the 'test of time', they are unlikely to be replaced as the standard in the near future. Instead of being replaced, the standard is more likely to be 'supplemented'. However, the design and presentation of these ECG visualisation supplements need to be universally standardised. Subsequent to the development of 'standardised supplements', as a requirement, they could then be integrated into all ECG machines. We recognise that without intuitive software and interactivity on mobile devices (e.g. tablet PCs), it is impractical to integrate the more advanced ECG visualisation methods into routine practice (i.e. epicardial mapping using an inverse solution).","container-title":"Journal of Electrocardiology","DOI":"10.1016/j.jelectrocard.2013.01.008","ISSN":"1532-8430","issue":"3","journalAbbreviation":"J Electrocardiol","language":"eng","note":"PMID: 23462202","page":"182-196","source":"PubMed","title":"Methods for presenting and visualising electrocardiographic data: From temporal signals to spatial imaging","title-short":"Methods for presenting and visualising electrocardiographic data","volume":"46","author":[{"family":"Bond","given":"Raymond R."},{"family":"Finlay","given":"Dewar D."},{"family":"Nugent","given":"Chris D."},{"family":"Moore","given":"George"},{"family":"Guldenring","given":"Daniel"}],"issued":{"date-parts":[["2013",6]]}}}],"schema":""} 53. Finally, new studies that evaluate diagnostic CDSS would ideally focus on sensitivity, specificity, positive predictive value and negative predictive value of CDSS algorithms and use consistent definitions of MI. Studies that also use consistent definitions and outcomes between them, would help with the development of a successful CDSS algorithm that integrate multiple components to provide an effective clinical aid.Summary CDSS are increasingly prevalent in healthcare and in combination with computer-aided decision and point-of-care biomarkers, they could provide a way of improving the accuracy of pre-hospital diagnosis and outcomes of treatment. With risks associated with delayed treatment of ACS and, alternatively, pressures on hospital resources such as cardiac cath-lab activation, there is an opportunity to create an efficient and safe diagnostic pathway prior to hospital admission. This review has highlighted the importance of patient history in diagnosis but also the potential for combining components such as biomarkers and computer-aided decision ECG interpretation in the integration of CDSS for suspected ACS. References1 ADDIN ZOTERO_BIBL {"uncited":[],"omitted":[],"custom":[]} CSL_BIBLIOGRAPHY . British Heart Foundation. Cardiovascular Disease UK Statistics Factsheet. November 2018. . Accessed November 5, 2018.2. Information Services Division. Scottish Heart Disease Statistics. Year Ending 31 March 2017. . Accessed October 26, 2018.3. Scottish Intercollegiate Guidelines Network (SIGN). Acute Coronary Syndrome. Edinburgh: SIGN; 2016. . Accessed October 26, 2018.4. National Institute for Health and Care Excellance. Myocardial Infarction with ST-Segment Elevation: Acute Management: Guidance and Guidelines.; 2013. . Accessed October 10, 2018.5. García-García C, Subirana I, Sala J, et al. 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Ann Intern Med. 2011;155(8):529-536. doi:10.7326/0003-4819-155-8-201110180-0000929. McGinn T, Wyer P, McCullagh L, et al. Diagnosis; Clinical Prediction Rules. In: Users’ Guides to the Medical Literature. A Manual for Evidence-Based Clinical Practice. 3rd ed. New York: McGraw-Hill; 2015:407-418.30. Gellerstedt M, Rawshani N, Herlitz J, et al. Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support? A cohort of patients with chest pain. Int J Cardiol. 2016;220:734-738. doi:10.1016/j.ijcard.2016.06.28131. Sakai T, Nishiyama O, Onodera M, et al. Predictive ability and efficacy for shortening door-to-balloon time of a new prehospital electrocardiogram-transmission flow chart in patients with ST-elevation myocardial infarction - Results of the CASSIOPEIA study. J Cardiol. 2018;72(4):335-342. doi:10.1016/j.jjcc.2018.03.01132. Bruins Slot MHE, Rutten FH, van der Heijden GJMG, Geersing GJ, Glatz JFC, Hoes AW. Diagnosing acute coronary syndrome in primary care: comparison of the physicians’ risk estimation and a clinical decision rule. Fam Pract. 2011;28(3):323-328. doi:10.1093/fampra/cmq11633. Grijseels EW, Deckers JW, Hoes AW, et al. Implementation of a pre-hospital decision rule in general practice. Triage of patients with suspected myocardial infarction. Eur Heart J. 1996;17(1):89-95.34. Wilson RE, Kado HS, Percy RF, et al. An algorithm for identification of ST-elevation myocardial infarction patients by emergency medicine services. Am J Emerg Med. 2013;31(7):1098-1102. doi:10.1016/j.ajem.2013.04.01335. Ishak M, Ali D, Fokkert MJ, et al. Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score. Eur Heart J Acute Cardiovasc Care. 2018;7(2):102-110. doi:10.1177/204887261668711636. Thygesen K, Alpert JS, White HD, et al. Universal definition of myocardial infarction. Circulation. 2007;116(22):2634-2653. doi:10.1161/CIRCULATIONAHA.107.18739737. Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. Circulation. 2012;126(16):2020-2035. doi:10.1161/CIR.0b013e31826e105838. Shah ASV, Anand A, Sandoval Y, et al. High-sensitivity cardiac troponin I at presentation in patients with suspected acute coronary syndrome: a cohort study. Lancet Lond Engl. 2015;386(10012):2481-2488. doi:10.1016/S0140-6736(15)00391-839. Than MP, Pickering JW, Sandoval Y, et al. Machine Learning to Predict the Likelihood of Acute Myocardial Infarction. Circulation. August 2019. doi:10.1161/CIRCULATIONAHA.119.04198040. Chapman AR, Stewart S, Mills NL. Contemporary point of care cardiac troponin testing in suspected acute coronary syndrome. Heart. February 2019:heartjnl-2018-314306. doi:10.1136/heartjnl-2018-31430641. Six AJ, Cullen L, Backus BE, et al. The HEART score for the assessment of patients with chest pain in the emergency department: a multinational validation study. Crit Pathw Cardiol. 2013;12(3):121-126. doi:10.1097/HPC.0b013e31828b327e42. Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA. 2000;284(7):835-842.43. Fox KAA, Dabbous OH, Goldberg RJ, et al. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ. 2006;333(7578):1091. doi:10.1136/bmj.38985.646481.5544. Garvey JL, Zegre-Hemsey J, Gregg R, Studnek JR. Electrocardiographic diagnosis of ST segment elevation myocardial infarction: An evaluation of three automated interpretation algorithms. J Electrocardiol. 2016;49(5):728-732. doi:10.1016/j.jelectrocard.2016.04.01045. Petrick N, Sahiner B, Armato SG, et al. Evaluation of computer-aided detection and diagnosis systems. Med Phys. 2013;40(8). doi:10.1118/1.481631046. Clark EN, Sejersten M, Clemmensen P, Macfarlane PW. Automated electrocardiogram interpretation programs versus cardiologists’ triage decision making based on teletransmitted data in patients with suspected acute coronary syndrome. Am J Cardiol. 2010;106(12):1696-1702. doi:10.1016/j.amjcard.2010.07.04747. Le May MR, Dionne R, Maloney J, et al. Diagnostic performance and potential clinical impact of advanced care paramedic interpretation of ST-segment elevation myocardial infarction in the field. CJEM. 2006;8(6):401-407.48. Xiao R, Xu Y, Pelter MM, Mortara DW, Hu X. A Deep Learning Approach to Examine Ischemic ST Changes in Ambulatory ECG Recordings. AMIA Summits Transl Sci Proc. 2018;2018:256-262.49. Bond RR, Novotny T, Andrsova I, et al. Automation bias in medicine: The influence of automated diagnoses on interpreter accuracy and uncertainty when reading electrocardiograms. J Electrocardiol. 2018;51(6S):S6-S11. doi:10.1016/j.jelectrocard.2018.08.00750. Liberati EG, Ruggiero F, Galuppo L, et al. What hinders the uptake of computerized decision support systems in hospitals? A qualitative study and framework for implementation. Implement Sci IS. 2017;12(1):113. doi:10.1186/s13012-017-0644-251. Cairns AW, Bond RR, Finlay DD, et al. A computer-human interaction model to improve the diagnostic accuracy and clinical decision-making during 12-lead electrocardiogram interpretation. J Biomed Inform. 2016;64:93-107. doi:10.1016/j.jbi.2016.09.01652. Bond RR, Zhu T, Finlay DD, et al. Assessing computerized eye tracking technology for gaining insight into expert interpretation of the 12-lead electrocardiogram: an objective quantitative approach. J Electrocardiol. 2014;47(6):895-906. doi:10.1016/j.jelectrocard.2014.07.01153. Bond RR, Finlay DD, Nugent CD, Moore G, Guldenring D. Methods for presenting and visualising electrocardiographic data: From temporal signals to spatial imaging. J Electrocardiol. 2013;46(3):182-196. doi:10.1016/j.jelectrocard.2013.01.008Figure legends:Figure 1. Flow chart of literature search and selection processTable 1. Study characteristicsTable 2. Results of the analysis of the outcomes, sensitivities, specificity, positive Predictive value and negative predictive value of the individual studies.Table 3. Mean of combined clinical decision support systems accuracy with incorporated componentsStudyStudy typeCDSS modelYearMean ageNo. patientsLocationPrehospital setting***Type of ACS analysed*Use of ECGUse of historyUse of biomarkerUse of vital signs**BiasGrijseels et al. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"wcpiv7k6","properties":{"formattedCitation":"[24]","plainCitation":"[24]","noteIndex":0},"citationItems":[{"id":478,"uris":[""],"uri":[""],"itemData":{"id":478,"type":"article-journal","title":"Implementation of a pre-hospital decision rule in general practice. Triage of patients with suspected myocardial infarction","container-title":"European Heart Journal","page":"89-95","volume":"17","issue":"1","source":"PubMed","abstract":"OBJECTIVE: To improve pre-hospital triage of patients with suspected acute cardiac disease.\nDESIGN: Prospective study. SUBJECTS. Patients with symptoms suggestive of acute cardiac pathology, who were seen by a general practitioner, for whom acute admission into hospital was requested, and in whom a pre-hospital electrocardiogram was recorded by the ambulance service.\nMETHODS: The study consisted of two phases. In the first phase, a decision rule was developed based on clinical characteristics and electrocardiographic findings in 1005 patients with suspected acute cardiac pathology. In the second phase, the decision rule was prospectively validated. Symptoms were recorded by a standardized questionnaire by the general practitioner and a computerized electrocardiogram was made by the ambulance nurses at the patient's home. Three electrocardiographic outcomes were available: 'normal electrocardiogram', 'possible myocardial infarction' or 'extensive myocardial infarction'. By use of the predictive model, the general practitioner could decide if hospitalization was necessary or not.\nMAIN OUTCOME MEASUREMENTS: Identification of patients at low (stable angina, atypical chest pain, other pathology) and high (myocardial infarction, unstable angina) probability of acute cardiac pathology.\nRESULTS: Among 977 patients with a complete pre-hospital evaluation in the validation phase of the study, the decision rule recommended 'no hospitalization' in 227 patients (23%). The general practitioner followed this advice in 44% of these patients. Although seven of them developed a non-Q wave myocardial infarction, no complications occurred in patients not admitted. In addition, the general practitioner did not hospitalize 19 (2%) of 750 patients for whom the decision rule recommended admission. Pre-hospital triage by the general practitioner resulted in a 12% (118 of 977 patients) reduction of the number of patients admitted to the Coronary Care Units.\nCONCLUSIONS: Pre-hospital triage by the general practitioner was facilitated using a standardized questionnaire and pre-hospital electrocardiography, and resulted in a reduction in the number of patients admitted to the Coronary Care Unit, and proved to be safe.","ISSN":"0195-668X","note":"PMID: 8682136","journalAbbreviation":"Eur. Heart J.","language":"eng","author":[{"family":"Grijseels","given":"E. W."},{"family":"Deckers","given":"J. W."},{"family":"Hoes","given":"A. W."},{"family":"Boersma","given":"E."},{"family":"Hartman","given":"J. A."},{"family":"Does","given":"E.","non-dropping-particle":"van der"},{"family":"Simoons","given":"M. L."}],"issued":{"date-parts":[["1996",1]]}}}],"schema":""} [33]Prospectivetwo-phaseQuestionnaire and ECG algorithm199565.6977NetherlandsGPACSYesYesNoYesAt risk of biasBruins et al. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ShHHyttv","properties":{"formattedCitation":"[22]","plainCitation":"[22]","noteIndex":0},"citationItems":[{"id":447,"uris":[""],"uri":[""],"itemData":{"id":447,"type":"article-journal","title":"Diagnosing acute coronary syndrome in primary care: comparison of the physicians' risk estimation and a clinical decision rule","container-title":"Family Practice","page":"323-328","volume":"28","issue":"3","source":"PubMed","abstract":"BACKGROUND: Diagnosing acute coronary syndrome (ACS) in a primary care setting poses a diagnostic dilemma for physicians.\nOBJECTIVE: We directly compared the diagnostic accuracy of a clinical decision rule (CDR) based on history taking and physical examination in suspected ACS with the risk estimates of the attending GP.\nMETHODS: In a prospective multicenter study, patients suspected of ACS were included by the GP. GPs were asked to estimate the probability (0%-100%) of the presence of ACS. GPs collected patient data, but they were not aware of the CDR and did not score the patient accordingly.\nRESULTS: Two hundred and ninety-eight patients were included (52% female, mean age 66 years, 22% ACS). The area under the receiver operating characteristic (ROC) curve (AUC) was 0.75 [95% confidence interval (CI) 0.68-0.82] for the GP risk estimate and 0.66 (95% CI 0.58-0.73) for the CDR. There was an agreement between the risk estimation of the GP and a CDR in 51% and the prevalence of ACS in predefined low-, intermediate- and high-risk groups was similar for the GP and CDR estimates. In the low-risk group, according to the GP, four patients (8.2%) suffered an ACS. These four patients were all identified by the decision rule as high risk.\nCONCLUSIONS: The GP classified patients as ACS or no ACS more adequately than the CDR, judged by the AUC. However, the use of a CDR in patients that are considered at low risk for ACS by the GP could reduce the amount of missed myocardial infarctions.","DOI":"10.1093/fampra/cmq116","ISSN":"1460-2229","note":"PMID: 21239470","title-short":"Diagnosing acute coronary syndrome in primary care","journalAbbreviation":"Fam Pract","language":"eng","author":[{"family":"Bruins Slot","given":"M. H. E."},{"family":"Rutten","given":"F. H."},{"family":"Heijden","given":"G. J. M. G.","non-dropping-particle":"van der"},{"family":"Geersing","given":"G. J."},{"family":"Glatz","given":"J. F. C."},{"family":"Hoes","given":"A. W."}],"issued":{"date-parts":[["2011",6]]}}}],"schema":""} [32]Prospective multi-centreGP-based clinical decision rule201066336NetherlandsGPACSNoYesNoYesAt risk of biasBhalla et al. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"DTHAfmhv","properties":{"formattedCitation":"[19]","plainCitation":"[19]","noteIndex":0},"citationItems":[{"id":445,"uris":[""],"uri":[""],"itemData":{"id":445,"type":"article-journal","title":"Prehospital electrocardiographic computer identification of ST-segment elevation myocardial infarction","container-title":"Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors","page":"211-216","volume":"17","issue":"2","source":"PubMed","abstract":"BACKGROUND: Identifying ST-segment elevation myocardial infarctions (STEMIs) in the field can decrease door-to-balloon times. Paramedics may use a computer algorithm to help them interpret prehospital electrocariograms (ECGs). It is unknown how accurately the computer can identify STEMIs.\nOBJECTIVES: To Determine the sensitivity and specificity of prehospital ECGs in identifying patients with STEMI.\nMETHODS: Retrospective cross-sectional study of 200 prehospital ECGs acquired using Lifepak 12 monitors and transmitted by one of more than 20 emergency medical services (EMS) agencies to the emergency department (ED) of a Summa Akron City Hospital, a level 1 trauma center between January 1, 2007, and February 18, 2010. The ED sees more than 73,000 adult patients and treats 120 STEMIs annually. The laboratory performs 3,400 catheterizations annually. The first 100 patients with a diagnosis of STEMI and cardiac catheterization laboratory activation from the ED were analyzed. For comparison, a control group of 100 other ECGs from patients without a STEMI were randomly selected from our Medtronic database using a random-number generator. For patients with STEMI, an accurate computer interpretation was \"acute MI suspected.\" Other interpretations were counted as misses. Specificity and sensitivity were calculated with confidence intervals (CIs). The sample size was determined a priori for a 95% CI of ±10%.\nRESULTS: Zero control patients were incorrectly labeled \"acute MI suspected.\" The specificity was 100% (100/100; 95% CI 0.96-1.0), whereas the sensitivity was 58% (58/100; 95% CI 0.48-0.67). This would have resulted in 42 missed cardiac catheterization laboratory activations, but zero inappropriate activations. The most common incorrect interpretation of STEMI ECGs by the computer was \"data quality prohibits interpretation,\" followed by \"abnormal ECG unconfirmed.\"\nCONCLUSIONS: Prehospital computer interpretation is not sensitive for STEMI identification and should not be used as a single method for prehospital activation of the cardiac catheterizing laboratory. Because of its high specificity, it may serve as an adjunct to interpretation.","DOI":"10.3109/10903127.2012.722176","ISSN":"1545-0066","note":"PMID: 23066910","journalAbbreviation":"Prehosp Emerg Care","language":"eng","author":[{"family":"Bhalla","given":"Mary Colleen"},{"family":"Mencl","given":"Francis"},{"family":"Gist","given":"Mikki Amber"},{"family":"Wilber","given":"Scott"},{"family":"Zalewski","given":"Jon"}],"issued":{"date-parts":[["2013",6]]}}}],"schema":""} [20]Retrospective cross-sectionalComputer-based ECG algorithm2012no info412USAEMSSTEMIYesNoNoNoAt risk of biasWilson et al. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"7zjBwnf6","properties":{"formattedCitation":"[18]","plainCitation":"[18]","noteIndex":0},"citationItems":[{"id":220,"uris":[""],"uri":[""],"itemData":{"id":220,"type":"article-journal","title":"An algorithm for identification of ST-elevation myocardial infarction patients by emergency medicine services","container-title":"The American Journal of Emergency Medicine","page":"1098-1102","volume":"31","issue":"7","source":"PubMed","abstract":"OBJECTIVE: ST-elevation myocardial infarction (STEMI) identification by emergency medicine services (EMS) leading to pre-hospital catheterization laboratory (CL) activation shortens ischemic time and improves outcomes. We examined the incremental value of addition of a screening clinical tool (CT), containing clinical information and a Zoll electrocardiogram (ECG)-resident STEMI identification program (ZI) to ZI alone.\nMETHODS: All EMS-performed and ZI-analyzed ECGs transmitted to a percutaneous coronary intervention hospital from October 2009 to January 2011 were reviewed for diagnostic accuracy. ZI performance was also compared to ECG interpretations by 2 experienced readers The CT was then retrospectively applied to determine the incremental benefit above the ZI alone.\nRESULTS: ST-elevation myocardial infarction was confirmed in 23 (7.5%) of 305 patients. ZI was positive in 37 (12.1%): sensitivity: 95.6% and specificity: 94.6%, positive predictive value (PPV), 59.5%, negative predictive value (NPV), 99.6%, and accuracy of 93.8%. Moderate agreement was observed among the readers and ZI. CT criteria for CL activation were met in 24 (7.8%): 20 (83.3%) were confirmed STEMIs: sensitivity: 86.9%, specificity: 98.5%, a PPV: 83.3%, and NPV: 98.6%, accuracy of 97.7%. CT + ZI increased PPV (P<0.05) and specificity (P<0.003) by reducing false positive STEMI identifications from 15 (4.9%) to 4 (1.3%).\nCONCLUSIONS: In an urban cohort of all EMS transmitted ECGs, ZI has high sensitivity and specificity for STEMI identification. Whereas the PPV was low, reflecting both low STEMI prevalence and presence of STEMI-mimics, the NPV was very high. These findings suggest that a simplified CT combined with computer STEMI interpretation can identify patients for pre-hospital CL activation. Confirmation of these results could improve the design of STEMI care systems.","DOI":"10.1016/j.ajem.2013.04.013","ISSN":"1532-8171","note":"PMID: 23706572","journalAbbreviation":"Am J Emerg Med","language":"eng","author":[{"family":"Wilson","given":"Ryan E."},{"family":"Kado","given":"Herman S."},{"family":"Percy","given":"Robert F."},{"family":"Butterfield","given":"Ryan C."},{"family":"Sabato","given":"Joseph"},{"family":"Strom","given":"Joel A."},{"family":"Box","given":"Lyndon C."}],"issued":{"date-parts":[["2013",7]]}}}],"schema":""} [34]Retrospective cross-sectionalClinical toolkit with ECG201356.8310USAEMSSTEMIYesYesNoNoLow risk of biasGellerstedt et al. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"wPDtHwkP","properties":{"formattedCitation":"[17]","plainCitation":"[17]","noteIndex":0},"citationItems":[{"id":441,"uris":[""],"uri":[""],"itemData":{"id":441,"type":"article-journal","title":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support? A cohort of patients with chest pain","container-title":"International Journal of Cardiology","page":"734-738","volume":"220","source":"PubMed","abstract":"BACKGROUND: To evaluate whether a computer-based decision support system could improve the allocation of patients with acute coronary syndrome (ACS) or a life-threatening condition (LTC). We hypothesised that a system of this kind would improve sensitivity without compromising specificity.\nMETHODS: A total of 2285 consecutive patients who dialed 112 due to chest pain were asked 10 specific questions and a prediction model was constructed based on the answers. We compared the sensitivity of the dispatchers' decisions with that of the model-based decision support model.\nRESULTS: A total of 2048 patients answered all 10 questions. Among the 235 patients with ACS, 194 were allocated the highest prioritisation by dispatchers (sensitivity 82.6%) and 41 patients were given a lower prioritisation (17.4% false negatives). The allocation suggested by the model used the highest prioritisation in 212 of the patients with ACS (sensitivity of 90.2%), while 23 patients were underprioritised (9.8% false negatives). The results were similar when the two systems were compared with regard to LTC and 30-day mortality. This indicates that computer-based decision support could be used either for increasing sensitivity or for saving resources. Three questions proved to be most important in terms of predicting ACS/LTC, [1] the intensity of pain, [2] the localisation of pain and [3] a history of ACS.\nCONCLUSION: Among patients with acute chest pain, computer-based decision support with a model based on a few fundamental questions could improve sensitivity and reduce the number of cases with the highest prioritisation without endangering the patients.","DOI":"10.1016/j.ijcard.2016.06.281","ISSN":"1874-1754","note":"PMID: 27393857","title-short":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support?","journalAbbreviation":"Int. J. Cardiol.","language":"eng","author":[{"family":"Gellerstedt","given":"Martin"},{"family":"Rawshani","given":"Nina"},{"family":"Herlitz","given":"Johan"},{"family":"B?ng","given":"Angela"},{"family":"Gelang","given":"Carita"},{"family":"Andersson","given":"Jan-Otto"},{"family":"Larsson","given":"Anna"},{"family":"Rawshani","given":"Araz"}],"issued":{"date-parts":[["2016",10,1]]}}}],"schema":""} [30]Prospective cross-sectionalTelephoned based Questionnaire201670.52,285SwedenEmergency dispatchACSNoYesNoNoAt risk of biasSakai et al. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"oQ3zPNDw","properties":{"formattedCitation":"[21]","plainCitation":"[21]","noteIndex":0},"citationItems":[{"id":437,"uris":[""],"uri":[""],"itemData":{"id":437,"type":"article-journal","title":"Predictive ability and efficacy for shortening door-to-balloon time of a new prehospital electrocardiogram-transmission flow chart in patients with ST-elevation myocardial infarction - Results of the CASSIOPEIA study","container-title":"Journal of Cardiology","page":"335-342","volume":"72","issue":"4","source":"PubMed","abstract":"BACKGROUND: The purposes of this study were to create a new flow-chart of prehospital electrocardiography (ECG)-transmission, evaluate its predictive ability for ST-elevation myocardial infarction (STEMI) and shorten door-to-balloon time (DTBT).\nMETHOD AND RESULTS: The new transmission flow-chart was created using symptoms from previous medical records of STEMI patients. A total of 4090 consecutive patients transferred emergently to our hospital were divided into two groups: those in ambulances with an ECG-transmission device with the new flow-chart (ECGT-FC) and those transferred without an ECG-transmission device (non-ECGT) groups. A STEMI group comprising walk-in patients during the same period was used as a control group. The predictive ability of STEMI and the effectiveness of shortening the DTBT by the new flow-chart of ECG-transmission was evaluated. In the ECGT-FC group, the prevalence of STEMI in the ECG-transmission by the new flow-chart were significantly higher than in the non-ECG-transmission patients (6.71% vs. 0.19%; p<0.001). The sensitivity and specificity of the new ECG-transmission flow-chart were 83.3% and 88.1%, respectively. The median DTBT was significantly shortened (p=0.045) and the prevalence of DTBT<90min was significantly higher in the ECGT-FC group (p=0.018) than the other groups.\nCONCLUSION: The sensitivity and specificity of the new flow-chart for ECG-transmission were high. The new flow-chart combined with an ECG-transmission device could detect STEMI efficiently and shorten DTBT.","DOI":"10.1016/j.jjcc.2018.03.011","ISSN":"1876-4738","note":"PMID: 29804908","journalAbbreviation":"J Cardiol","language":"eng","author":[{"family":"Sakai","given":"Toshiaki"},{"family":"Nishiyama","given":"Osamu"},{"family":"Onodera","given":"Masayuki"},{"family":"Matsuda","given":"Shigekatsu"},{"family":"Wakisawa","given":"Shinobu"},{"family":"Nakamura","given":"Motoyuki"},{"family":"Morino","given":"Yoshihiro"},{"family":"Itoh","given":"Tomonori"},{"literal":"CASSIOPEIA study group"}],"issued":{"date-parts":[["2018",10]]}}}],"schema":""} [31]Prospectivecase controlECG transmission flow chart201769.4347,989JapanEMSSTEMIYesYesNoYesAt risk of biasIshak et al. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"pO1jlaA0","properties":{"formattedCitation":"[20]","plainCitation":"[20]","noteIndex":0},"citationItems":[{"id":439,"uris":[""],"uri":[""],"itemData":{"id":439,"type":"article-journal","title":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score","container-title":"European Heart Journal. Acute Cardiovascular Care","page":"102-110","volume":"7","issue":"2","source":"PubMed","abstract":"BACKGROUND: The first study of the FamouS Triage project investigates the feasibility of ruling out a myocardial infarction in pre-hospital chest pain patients without electrocardiographic ST-segment elevation by using the modified HEART score at the patient's home, incorporating only a single highly sensitive troponin T measurement.\nMETHODS: A venous blood sample was drawn in the ambulance from 1127 consecutive chest pain patients for measurement of the pre-hospital highly sensitive troponin T levels, in order to establish a pre-hospital HEART score (i.e. the modified HEART score) and evaluate the possibility of triage at the patient's home. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) i.e. acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or death within 30 days after initial presentation.\nRESULTS: Two hundred and six patients (18%) developed a MACE during 30 days of follow-up. Thirty-six per cent of the patients ( n=403) had a low modified HEART score (0-3 points) and none of them developed a MACE during follow-up. Forty-four per cent of the patients ( n=494) had an intermediate modified HEART score (4-6 points) and 18% of them developed a MACE. Twenty per cent of the patients ( n=230) had a high modified HEART score (7-10 points) of which 52% developed a MACE during follow-up.\nCONCLUSION: It seems feasible to rule out a myocardial infarction at home in chest pain patients without ST-segment elevation by using the modified HEART score.\nTRIAL ID: NTR4205. Dutch Trial Register [ ]: trial number 4205.","DOI":"10.1177/2048872616687116","ISSN":"2048-8734","note":"PMID: 28084079","title-short":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage)","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","author":[{"family":"Ishak","given":"Maycel"},{"family":"Ali","given":"Danish"},{"family":"Fokkert","given":"Marion J."},{"family":"Slingerland","given":"Robbert J."},{"family":"Tolsma","given":"Rudolf T."},{"family":"Badings","given":"Erik"},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Eenennaam","given":"Fred","non-dropping-particle":"van"},{"family":"Mosterd","given":"Arend"},{"family":"Ten Berg","given":"Jurri?n M."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"}],"issued":{"date-parts":[["2018",3]]}}}],"schema":""} [35]Prospective cross-sectionalModified HEART score201863.81,127NetherlandsEMSMACE^YesYesYesYesLow risk of biasVan Dongen et al. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"OWObl2gt","properties":{"formattedCitation":"[23]","plainCitation":"[23]","noteIndex":0},"citationItems":[{"id":435,"uris":[""],"uri":[""],"itemData":{"id":435,"type":"article-journal","title":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study","container-title":"European Heart Journal. Acute Cardiovascular Care","page":"2048872618813846","source":"PubMed","abstract":"BACKGROUND:: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE).\nMETHODS:: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ? 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death.\nRESULTS:: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%).\nCONCLUSIONS:: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.","DOI":"10.1177/2048872618813846","ISSN":"2048-8734","note":"PMID: 30468395","title-short":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","author":[{"family":"Dongen","given":"Dominique N.","non-dropping-particle":"van"},{"family":"Tolsma","given":"Rudolf T."},{"family":"Fokkert","given":"Marion J."},{"family":"Badings","given":"Erik A."},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Slingerland","given":"Robbert J."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"},{"family":"Ottervanger","given":"Jan Paul"}],"issued":{"date-parts":[["2018",11,23]]}}}],"schema":""} [16]Prospective observationalModified HEART score201863.6823NetherlandsEMSNSTEMIYesYesYesYesLow risk of biasTable 1. Study characteristics* ACS includes STEMI ST elevation myocardial infarction; NSTEMI, non-ST elevation myocardial infarction and unstable angina. **Defined as either respiratory rate, oxygen saturations, heart rate, blood pressure, conscious level, or temperature. *** EMS, Emergency Medical services; GP, General Practitioner MI, myocardial infarction; ACS, acute coronary syndrome, ECG electrocardiogram. ^ MACE, major adverse cardiovascular event; defined as death (all cause), MI, primary cutaneous intervention, coronary artery bypass grafting or all-cause mortality.StudyPrimary OutcomeSensitivitySpecificityPPVNPVGrijseels et al. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"2R1BUkrj","properties":{"formattedCitation":"[24]","plainCitation":"[24]","noteIndex":0},"citationItems":[{"id":478,"uris":[""],"uri":[""],"itemData":{"id":478,"type":"article-journal","title":"Implementation of a pre-hospital decision rule in general practice. Triage of patients with suspected myocardial infarction","container-title":"European Heart Journal","page":"89-95","volume":"17","issue":"1","source":"PubMed","abstract":"OBJECTIVE: To improve pre-hospital triage of patients with suspected acute cardiac disease.\nDESIGN: Prospective study. SUBJECTS. Patients with symptoms suggestive of acute cardiac pathology, who were seen by a general practitioner, for whom acute admission into hospital was requested, and in whom a pre-hospital electrocardiogram was recorded by the ambulance service.\nMETHODS: The study consisted of two phases. In the first phase, a decision rule was developed based on clinical characteristics and electrocardiographic findings in 1005 patients with suspected acute cardiac pathology. In the second phase, the decision rule was prospectively validated. Symptoms were recorded by a standardized questionnaire by the general practitioner and a computerized electrocardiogram was made by the ambulance nurses at the patient's home. Three electrocardiographic outcomes were available: 'normal electrocardiogram', 'possible myocardial infarction' or 'extensive myocardial infarction'. By use of the predictive model, the general practitioner could decide if hospitalization was necessary or not.\nMAIN OUTCOME MEASUREMENTS: Identification of patients at low (stable angina, atypical chest pain, other pathology) and high (myocardial infarction, unstable angina) probability of acute cardiac pathology.\nRESULTS: Among 977 patients with a complete pre-hospital evaluation in the validation phase of the study, the decision rule recommended 'no hospitalization' in 227 patients (23%). The general practitioner followed this advice in 44% of these patients. Although seven of them developed a non-Q wave myocardial infarction, no complications occurred in patients not admitted. In addition, the general practitioner did not hospitalize 19 (2%) of 750 patients for whom the decision rule recommended admission. Pre-hospital triage by the general practitioner resulted in a 12% (118 of 977 patients) reduction of the number of patients admitted to the Coronary Care Units.\nCONCLUSIONS: Pre-hospital triage by the general practitioner was facilitated using a standardized questionnaire and pre-hospital electrocardiography, and resulted in a reduction in the number of patients admitted to the Coronary Care Unit, and proved to be safe.","ISSN":"0195-668X","note":"PMID: 8682136","journalAbbreviation":"Eur. Heart J.","language":"eng","author":[{"family":"Grijseels","given":"E. W."},{"family":"Deckers","given":"J. W."},{"family":"Hoes","given":"A. W."},{"family":"Boersma","given":"E."},{"family":"Hartman","given":"J. A."},{"family":"Does","given":"E.","non-dropping-particle":"van der"},{"family":"Simoons","given":"M. L."}],"issued":{"date-parts":[["1996",1]]}}}],"schema":""} [33]Diagnosis of ACS97.0%13.0%52.0%92.0%Bruins et al. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"4PwvhYfJ","properties":{"formattedCitation":"[22]","plainCitation":"[22]","noteIndex":0},"citationItems":[{"id":447,"uris":[""],"uri":[""],"itemData":{"id":447,"type":"article-journal","title":"Diagnosing acute coronary syndrome in primary care: comparison of the physicians' risk estimation and a clinical decision rule","container-title":"Family Practice","page":"323-328","volume":"28","issue":"3","source":"PubMed","abstract":"BACKGROUND: Diagnosing acute coronary syndrome (ACS) in a primary care setting poses a diagnostic dilemma for physicians.\nOBJECTIVE: We directly compared the diagnostic accuracy of a clinical decision rule (CDR) based on history taking and physical examination in suspected ACS with the risk estimates of the attending GP.\nMETHODS: In a prospective multicenter study, patients suspected of ACS were included by the GP. GPs were asked to estimate the probability (0%-100%) of the presence of ACS. GPs collected patient data, but they were not aware of the CDR and did not score the patient accordingly.\nRESULTS: Two hundred and ninety-eight patients were included (52% female, mean age 66 years, 22% ACS). The area under the receiver operating characteristic (ROC) curve (AUC) was 0.75 [95% confidence interval (CI) 0.68-0.82] for the GP risk estimate and 0.66 (95% CI 0.58-0.73) for the CDR. There was an agreement between the risk estimation of the GP and a CDR in 51% and the prevalence of ACS in predefined low-, intermediate- and high-risk groups was similar for the GP and CDR estimates. In the low-risk group, according to the GP, four patients (8.2%) suffered an ACS. These four patients were all identified by the decision rule as high risk.\nCONCLUSIONS: The GP classified patients as ACS or no ACS more adequately than the CDR, judged by the AUC. However, the use of a CDR in patients that are considered at low risk for ACS by the GP could reduce the amount of missed myocardial infarctions.","DOI":"10.1093/fampra/cmq116","ISSN":"1460-2229","note":"PMID: 21239470","title-short":"Diagnosing acute coronary syndrome in primary care","journalAbbreviation":"Fam Pract","language":"eng","author":[{"family":"Bruins Slot","given":"M. H. E."},{"family":"Rutten","given":"F. H."},{"family":"Heijden","given":"G. J. M. G.","non-dropping-particle":"van der"},{"family":"Geersing","given":"G. J."},{"family":"Glatz","given":"J. F. C."},{"family":"Hoes","given":"A. W."}],"issued":{"date-parts":[["2011",6]]}}}],"schema":""} [32]ACS diagnosis97.0%10.0%23.0%92.0%Bhalla et al. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"J2NiEq29","properties":{"formattedCitation":"[19]","plainCitation":"[19]","noteIndex":0},"citationItems":[{"id":445,"uris":[""],"uri":[""],"itemData":{"id":445,"type":"article-journal","title":"Prehospital electrocardiographic computer identification of ST-segment elevation myocardial infarction","container-title":"Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors","page":"211-216","volume":"17","issue":"2","source":"PubMed","abstract":"BACKGROUND: Identifying ST-segment elevation myocardial infarctions (STEMIs) in the field can decrease door-to-balloon times. Paramedics may use a computer algorithm to help them interpret prehospital electrocariograms (ECGs). It is unknown how accurately the computer can identify STEMIs.\nOBJECTIVES: To Determine the sensitivity and specificity of prehospital ECGs in identifying patients with STEMI.\nMETHODS: Retrospective cross-sectional study of 200 prehospital ECGs acquired using Lifepak 12 monitors and transmitted by one of more than 20 emergency medical services (EMS) agencies to the emergency department (ED) of a Summa Akron City Hospital, a level 1 trauma center between January 1, 2007, and February 18, 2010. The ED sees more than 73,000 adult patients and treats 120 STEMIs annually. The laboratory performs 3,400 catheterizations annually. The first 100 patients with a diagnosis of STEMI and cardiac catheterization laboratory activation from the ED were analyzed. For comparison, a control group of 100 other ECGs from patients without a STEMI were randomly selected from our Medtronic database using a random-number generator. For patients with STEMI, an accurate computer interpretation was \"acute MI suspected.\" Other interpretations were counted as misses. Specificity and sensitivity were calculated with confidence intervals (CIs). The sample size was determined a priori for a 95% CI of ±10%.\nRESULTS: Zero control patients were incorrectly labeled \"acute MI suspected.\" The specificity was 100% (100/100; 95% CI 0.96-1.0), whereas the sensitivity was 58% (58/100; 95% CI 0.48-0.67). This would have resulted in 42 missed cardiac catheterization laboratory activations, but zero inappropriate activations. The most common incorrect interpretation of STEMI ECGs by the computer was \"data quality prohibits interpretation,\" followed by \"abnormal ECG unconfirmed.\"\nCONCLUSIONS: Prehospital computer interpretation is not sensitive for STEMI identification and should not be used as a single method for prehospital activation of the cardiac catheterizing laboratory. Because of its high specificity, it may serve as an adjunct to interpretation.","DOI":"10.3109/10903127.2012.722176","ISSN":"1545-0066","note":"PMID: 23066910","journalAbbreviation":"Prehosp Emerg Care","language":"eng","author":[{"family":"Bhalla","given":"Mary Colleen"},{"family":"Mencl","given":"Francis"},{"family":"Gist","given":"Mikki Amber"},{"family":"Wilber","given":"Scott"},{"family":"Zalewski","given":"Jon"}],"issued":{"date-parts":[["2013",6]]}}}],"schema":""} [20]STEMI diagnosis58.0%100.0%100.0%30.0%Wilson et al. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"6eUZv0gj","properties":{"formattedCitation":"[18]","plainCitation":"[18]","noteIndex":0},"citationItems":[{"id":220,"uris":[""],"uri":[""],"itemData":{"id":220,"type":"article-journal","title":"An algorithm for identification of ST-elevation myocardial infarction patients by emergency medicine services","container-title":"The American Journal of Emergency Medicine","page":"1098-1102","volume":"31","issue":"7","source":"PubMed","abstract":"OBJECTIVE: ST-elevation myocardial infarction (STEMI) identification by emergency medicine services (EMS) leading to pre-hospital catheterization laboratory (CL) activation shortens ischemic time and improves outcomes. We examined the incremental value of addition of a screening clinical tool (CT), containing clinical information and a Zoll electrocardiogram (ECG)-resident STEMI identification program (ZI) to ZI alone.\nMETHODS: All EMS-performed and ZI-analyzed ECGs transmitted to a percutaneous coronary intervention hospital from October 2009 to January 2011 were reviewed for diagnostic accuracy. ZI performance was also compared to ECG interpretations by 2 experienced readers The CT was then retrospectively applied to determine the incremental benefit above the ZI alone.\nRESULTS: ST-elevation myocardial infarction was confirmed in 23 (7.5%) of 305 patients. ZI was positive in 37 (12.1%): sensitivity: 95.6% and specificity: 94.6%, positive predictive value (PPV), 59.5%, negative predictive value (NPV), 99.6%, and accuracy of 93.8%. Moderate agreement was observed among the readers and ZI. CT criteria for CL activation were met in 24 (7.8%): 20 (83.3%) were confirmed STEMIs: sensitivity: 86.9%, specificity: 98.5%, a PPV: 83.3%, and NPV: 98.6%, accuracy of 97.7%. CT + ZI increased PPV (P<0.05) and specificity (P<0.003) by reducing false positive STEMI identifications from 15 (4.9%) to 4 (1.3%).\nCONCLUSIONS: In an urban cohort of all EMS transmitted ECGs, ZI has high sensitivity and specificity for STEMI identification. Whereas the PPV was low, reflecting both low STEMI prevalence and presence of STEMI-mimics, the NPV was very high. These findings suggest that a simplified CT combined with computer STEMI interpretation can identify patients for pre-hospital CL activation. Confirmation of these results could improve the design of STEMI care systems.","DOI":"10.1016/j.ajem.2013.04.013","ISSN":"1532-8171","note":"PMID: 23706572","journalAbbreviation":"Am J Emerg Med","language":"eng","author":[{"family":"Wilson","given":"Ryan E."},{"family":"Kado","given":"Herman S."},{"family":"Percy","given":"Robert F."},{"family":"Butterfield","given":"Ryan C."},{"family":"Sabato","given":"Joseph"},{"family":"Strom","given":"Joel A."},{"family":"Box","given":"Lyndon C."}],"issued":{"date-parts":[["2013",7]]}}}],"schema":""} [34]STEMI diagnosis86.9%98.5%83.3%98.6%Gellerstedt et al. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"HgG17wNa","properties":{"formattedCitation":"[17]","plainCitation":"[17]","noteIndex":0},"citationItems":[{"id":441,"uris":[""],"uri":[""],"itemData":{"id":441,"type":"article-journal","title":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support? A cohort of patients with chest pain","container-title":"International Journal of Cardiology","page":"734-738","volume":"220","source":"PubMed","abstract":"BACKGROUND: To evaluate whether a computer-based decision support system could improve the allocation of patients with acute coronary syndrome (ACS) or a life-threatening condition (LTC). We hypothesised that a system of this kind would improve sensitivity without compromising specificity.\nMETHODS: A total of 2285 consecutive patients who dialed 112 due to chest pain were asked 10 specific questions and a prediction model was constructed based on the answers. We compared the sensitivity of the dispatchers' decisions with that of the model-based decision support model.\nRESULTS: A total of 2048 patients answered all 10 questions. Among the 235 patients with ACS, 194 were allocated the highest prioritisation by dispatchers (sensitivity 82.6%) and 41 patients were given a lower prioritisation (17.4% false negatives). The allocation suggested by the model used the highest prioritisation in 212 of the patients with ACS (sensitivity of 90.2%), while 23 patients were underprioritised (9.8% false negatives). The results were similar when the two systems were compared with regard to LTC and 30-day mortality. This indicates that computer-based decision support could be used either for increasing sensitivity or for saving resources. Three questions proved to be most important in terms of predicting ACS/LTC, [1] the intensity of pain, [2] the localisation of pain and [3] a history of ACS.\nCONCLUSION: Among patients with acute chest pain, computer-based decision support with a model based on a few fundamental questions could improve sensitivity and reduce the number of cases with the highest prioritisation without endangering the patients.","DOI":"10.1016/j.ijcard.2016.06.281","ISSN":"1874-1754","note":"PMID: 27393857","title-short":"Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support?","journalAbbreviation":"Int. J. Cardiol.","language":"eng","author":[{"family":"Gellerstedt","given":"Martin"},{"family":"Rawshani","given":"Nina"},{"family":"Herlitz","given":"Johan"},{"family":"B?ng","given":"Angela"},{"family":"Gelang","given":"Carita"},{"family":"Andersson","given":"Jan-Otto"},{"family":"Larsson","given":"Anna"},{"family":"Rawshani","given":"Araz"}],"issued":{"date-parts":[["2016",10,1]]}}}],"schema":""} [30]ACS92.2%41.0%17.0%97.0%Sakai et al. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"5jYnxOWn","properties":{"formattedCitation":"[21]","plainCitation":"[21]","noteIndex":0},"citationItems":[{"id":437,"uris":[""],"uri":[""],"itemData":{"id":437,"type":"article-journal","title":"Predictive ability and efficacy for shortening door-to-balloon time of a new prehospital electrocardiogram-transmission flow chart in patients with ST-elevation myocardial infarction - Results of the CASSIOPEIA study","container-title":"Journal of Cardiology","page":"335-342","volume":"72","issue":"4","source":"PubMed","abstract":"BACKGROUND: The purposes of this study were to create a new flow-chart of prehospital electrocardiography (ECG)-transmission, evaluate its predictive ability for ST-elevation myocardial infarction (STEMI) and shorten door-to-balloon time (DTBT).\nMETHOD AND RESULTS: The new transmission flow-chart was created using symptoms from previous medical records of STEMI patients. A total of 4090 consecutive patients transferred emergently to our hospital were divided into two groups: those in ambulances with an ECG-transmission device with the new flow-chart (ECGT-FC) and those transferred without an ECG-transmission device (non-ECGT) groups. A STEMI group comprising walk-in patients during the same period was used as a control group. The predictive ability of STEMI and the effectiveness of shortening the DTBT by the new flow-chart of ECG-transmission was evaluated. In the ECGT-FC group, the prevalence of STEMI in the ECG-transmission by the new flow-chart were significantly higher than in the non-ECG-transmission patients (6.71% vs. 0.19%; p<0.001). The sensitivity and specificity of the new ECG-transmission flow-chart were 83.3% and 88.1%, respectively. The median DTBT was significantly shortened (p=0.045) and the prevalence of DTBT<90min was significantly higher in the ECGT-FC group (p=0.018) than the other groups.\nCONCLUSION: The sensitivity and specificity of the new flow-chart for ECG-transmission were high. The new flow-chart combined with an ECG-transmission device could detect STEMI efficiently and shorten DTBT.","DOI":"10.1016/j.jjcc.2018.03.011","ISSN":"1876-4738","note":"PMID: 29804908","journalAbbreviation":"J Cardiol","language":"eng","author":[{"family":"Sakai","given":"Toshiaki"},{"family":"Nishiyama","given":"Osamu"},{"family":"Onodera","given":"Masayuki"},{"family":"Matsuda","given":"Shigekatsu"},{"family":"Wakisawa","given":"Shinobu"},{"family":"Nakamura","given":"Motoyuki"},{"family":"Morino","given":"Yoshihiro"},{"family":"Itoh","given":"Tomonori"},{"literal":"CASSIOPEIA study group"}],"issued":{"date-parts":[["2018",10]]}}}],"schema":""} [31]STEMI diagnosis83.3%88.1%6.7%99.8%Ishak et al. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"SQOSVOOH","properties":{"formattedCitation":"[20]","plainCitation":"[20]","noteIndex":0},"citationItems":[{"id":439,"uris":[""],"uri":[""],"itemData":{"id":439,"type":"article-journal","title":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage): ruling out a myocardial infarction at home with the modified HEART score","container-title":"European Heart Journal. Acute Cardiovascular Care","page":"102-110","volume":"7","issue":"2","source":"PubMed","abstract":"BACKGROUND: The first study of the FamouS Triage project investigates the feasibility of ruling out a myocardial infarction in pre-hospital chest pain patients without electrocardiographic ST-segment elevation by using the modified HEART score at the patient's home, incorporating only a single highly sensitive troponin T measurement.\nMETHODS: A venous blood sample was drawn in the ambulance from 1127 consecutive chest pain patients for measurement of the pre-hospital highly sensitive troponin T levels, in order to establish a pre-hospital HEART score (i.e. the modified HEART score) and evaluate the possibility of triage at the patient's home. The primary endpoint was the occurrence of a major adverse cardiac event (MACE) i.e. acute myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting or death within 30 days after initial presentation.\nRESULTS: Two hundred and six patients (18%) developed a MACE during 30 days of follow-up. Thirty-six per cent of the patients ( n=403) had a low modified HEART score (0-3 points) and none of them developed a MACE during follow-up. Forty-four per cent of the patients ( n=494) had an intermediate modified HEART score (4-6 points) and 18% of them developed a MACE. Twenty per cent of the patients ( n=230) had a high modified HEART score (7-10 points) of which 52% developed a MACE during follow-up.\nCONCLUSION: It seems feasible to rule out a myocardial infarction at home in chest pain patients without ST-segment elevation by using the modified HEART score.\nTRIAL ID: NTR4205. Dutch Trial Register [ ]: trial number 4205.","DOI":"10.1177/2048872616687116","ISSN":"2048-8734","note":"PMID: 28084079","title-short":"Fast assessment and management of chest pain patients without ST-elevation in the pre-hospital gateway (FamouS Triage)","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","author":[{"family":"Ishak","given":"Maycel"},{"family":"Ali","given":"Danish"},{"family":"Fokkert","given":"Marion J."},{"family":"Slingerland","given":"Robbert J."},{"family":"Tolsma","given":"Rudolf T."},{"family":"Badings","given":"Erik"},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Eenennaam","given":"Fred","non-dropping-particle":"van"},{"family":"Mosterd","given":"Arend"},{"family":"Ten Berg","given":"Jurri?n M."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"}],"issued":{"date-parts":[["2018",3]]}}}],"schema":""} [35]MACE100.0%43.0%28.5%100.0%Van Dongen et al. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"FUQIZok7","properties":{"formattedCitation":"[23]","plainCitation":"[23]","noteIndex":0},"citationItems":[{"id":435,"uris":[""],"uri":[""],"itemData":{"id":435,"type":"article-journal","title":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study","container-title":"European Heart Journal. Acute Cardiovascular Care","page":"2048872618813846","source":"PubMed","abstract":"BACKGROUND:: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE).\nMETHODS:: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ? 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death.\nRESULTS:: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%).\nCONCLUSIONS:: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.","DOI":"10.1177/2048872618813846","ISSN":"2048-8734","note":"PMID: 30468395","title-short":"Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome","journalAbbreviation":"Eur Heart J Acute Cardiovasc Care","language":"eng","author":[{"family":"Dongen","given":"Dominique N.","non-dropping-particle":"van"},{"family":"Tolsma","given":"Rudolf T."},{"family":"Fokkert","given":"Marion J."},{"family":"Badings","given":"Erik A."},{"family":"Sluis","given":"Aize","non-dropping-particle":"van der"},{"family":"Slingerland","given":"Robbert J."},{"family":"Hof","given":"Arnoud Wj","non-dropping-particle":"van 't"},{"family":"Ottervanger","given":"Jan Paul"}],"issued":{"date-parts":[["2018",11,23]]}}}],"schema":""} [16]MACE within 45 days96.0%29.0%21.0%97.0%Table 2. Results of the analysis of the outcomes, sensitivities, specificity, positive Predictive value and negative predictive value of the individual studies.* MACE, major adverse cardiovascular event; defined as death (all cause), MI, primary cutaneous intervention, coronary artery bypass grafting or all-cause mortality.PPV, positive predictive value; NPV, negative predictive value; ACS, acute coronary syndrome; STEMI, ST elevation myocardial infarction. Table 3. Mean of combined clinical decision support systems accuracy with incorporated componentsInvolved ECGInvolved HistoryInvolved BiomarkersInvolved Examination/vital signs*Mean ±SD (%)p-valueMean ±SD (%)p-valueMean ±SD (%)p-valueMean ±SD (%)p-valueSensitivity86.9 ±15.50.531*93.2 ±6.10.002**98.0 ±2.80.306*94.7 ±6.50.122Specificity61.9 ±38.20.262*46.1 ±34.70.197*36.0 ±9.90.27436.6 ±31.60.117*PPV48.6 ±36.80.339*33.1 ±26.10.054*24.7 ±5.30.462*26.2 ±16.50.101*NPV86.2 ±27.70.703*96.6 ±3.40.000**98.5 ±2.10.526*96.1 ±4.00.256*Equal Variance assumed by Levene’s test for heteroscedasticity **Statistical significance (2-tailed) for component accuracy in model inclusion compared to omission. ECG, electrocardiogram; SD, standard deviation; PPV, positive predictive value; NPV negative predictive value. Figure 1. Flow chart of literature search and selection processSupplementary material APPENDIXAppendix 1. Search terms OVID (Medline and EMBASE) Clinical decision support systems Clinical? decision? support? systems* Algor#thm Diagnos* Diagnos* adj(accuracy or differential* or decision* or tool*) Predict* Clinical? adj(pathway? or tool? or decision?) Triage.mp Pre-Hospital Pre-hospital* Pre?hospital* Emergency care.mp Point of care test* Point-of-care systems/ Early?diagnosis.mp Out?of?hospital* Emergency Medical Services/ Myocardial infarction exp.Acute coronary syndrome* acs.mp coronary adj(event* or disease* or arter*) myocard* infarct* myocard* isch?emia.mp STEMI.mp ST elevation adj(acute coro* syndrome or myocard* infarc*) NSTEMI.mp Non-ST elevation adj(acute coro* syndrome or myocard* infarc*) Steacs.mp Nsteacs.mp Heart adj(attack or pain or arrest) Heart arrest* Chest pain.mp Unstable angina.mp UA.mp Cardiac* Ischaem* Web of Science search terms TS=(“acute coronary syndrome*” OR “acs” OR “coronary adj(event* OR disease* OR arter*)” OR “myocard* infarct*” OR “myocard* isch?emia” OR “STEMI” OR “STEACS” OR “ST elevation adj(acute coro* syndrome OR myocard* infarc*)” OR “NSTEMI” OR “Non-ST elevation adj(acute coro* syndrome OR myocard* infarc*)” OR “NSTEACS” OR “heart attack”) AND TS=(“Clinical? decision? support? systems*” OR “Algor$thm” OR “Diagnos* adj(accuracy OR differential* OR decision* OR tool*)” OR “Predict* adj(tool? OR pathway?)” OR “Clinical? adj(pathway? OR tool? or decision?))” AND TS=(“Pre-hospital*” OR “Pre?hospital*” OR “Emergency care” OR “Point of care test*” OR “Point-of-care systems/” OR “Early?diagnosis” OR “Out?of?hospital*” OR “Emergency Medical Services/”) REFINE: English language, WEB of Science Core Collection, Research areas ( CARDIOVASCULAR SYSTEMS CARDIOLOGY, HEALTH CARE SCIENCES SERVICES, EMERGENCY MEDICINE, GENERAL INTERNAL MEDICINE, CRITICAL CARE MEDICINE, AUTOMATION CONTROL SYSTEMS) CINAHL Search terms Myocardial InfarctionTX Acute coronary syndrome* TX acs TX coronary N1 event* or disease* or arter* TX myocard* infarct* TX myocard* isch?emia TX stemi TX st elevation N1 acute coro* syndrome or myocard* infarc* TX nstemi TX non st elevation N1 acute coro* syndrome or myocard* infarc* TX steacs TX nsteacs TX Heart N1 attack or pain TX Chest pain TX Cardiac* TX Isch#em* Pre-hospital TX Prehospital* TX Pre#hospital* TX Emergency#care MH point-of-care Testing TX Early$diagnosis TX Out$of$hospital* MH Emergency Medical Services Clinical decision support systems MH Decision Support Systems, Clinical MH Algorithms Algor#thm TX Diagnos* w1 accuracy or differential* or decision* or tool* TX Predict* n1 tool* OR pathway* TX Clinical? n1 pathway* or tool* or decision* Cochrane Search Terms Myocardial Infarction“Acute (coronary or cardiac) syndrome?” “Acs” “coronary NEAR(event? or disease? or arter*)” “myocard* infarct*” “myocard* isch*emia” “stemi” “st elevation NEAR (acute coro* syndrome or myocard* infarc*)” “Nstemi” “Non st elevation NEAR(acute coro* syndrome? or myocard* infarc*)” “Steacs” “Nsteacs” “Heart NEAR(attack or pain)” “Chest pain” “Cardiac*” “Ischaem* heart disease*” Pre-Hospital “Pre-hospital*” “Emergency care” “Point of care test*” “Point-of-care system?” “Early diagnosi*” “Out of hospital” “Emergency Medical Services” Clinical decision support systems “Clinical decision support systems?” “Computeri?ed decision support systems?” “Algor*thm” “Diagnos*” “Diagnos* NEAR(accuracy or differential* or decision* or tool*)” “Predict*” “Predict * NEAR (pathway? or tool? or decision?)” “Clinical? NEAR (pathway? or tool? or decision?)” “Triage” Appendix 2.Data Extraction form template. Study numberDate of extractionExtractor nameTitleFirst AuthorPublication typeStudy typeLanguageStudy YearLocationSettingFundingParticipant locationStudy lengthAge greater than 18?Pre-hospital?Clinical decision support systems involved Examination/Vital signs?Clinical decision support systems involved Biomarkers?Clinical decision support systems involved ECGClinical decision support systems involved patient historyName of clinical decision support systems involvedDecision maker (GP/Paramedic/Computer etc.)Myocardial infarction definitionType of ACS examined (e.g. STEMI/NSTEMI/all ACS)Enrolment periodSampling MethodLength of time for outcome studyNumber of ParticipantsNumber lost to follow-upMean ageGender percentageOutcome 1 typeOutcome 1 percentageOutcome 1 numberOutcome 2 typeOutcome 2 percentageOutcome 2 numberIndependent predictorsSensitivitySpecificityPositive Predictive ValueNegative predictive Valuec-StatisticValidation?NotesQuality of Evidence (QUADAS)Include in study?Reasoning if not ................
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