Fast assessment and management of chest pain without ST-elevation in the pre-hospital gateway: rationale and design

Abstract

Background: For chest pain patients without ST-segment elevation in the pre-hospital setting, current clinical guidelines merely offer in-hospital risk stratification and management, as opposed to chest pain patients with ST-segment elevation for whom there is a straightforward pre-hospital strategy for diagnosis, medication regimen and logistics. The FAMOUS TRIAGE study will assess the effects of introducing a pre-hospital triage system that reliably stratifies chest pain patients without ST-segment elevation into 1) patients at high risk for NSTEMI requiring a direct transfer to a PCI-hospital; 2) patients at intermediate risk for a major adverse cardiac event (MACE) who could be evaluated at the nearest non-PCI hospital; and 3) patients at low risk for MACE (benign non-cardiac chest pain) who could have further evaluation at home or in a primary care setting.

Methods: The FAMOUS TRIAGE study will be performed in three phases. In the first phase an appropriate pre-hospital risk stratification tool will be designed for chest pain patients without ST-segment elevation by means of a retrospective and a prospective study. The second phase of the project represents the external validation of the risk stratification models, and in the third and final phase an optimal risk stratification tool will be implemented into clinical practice. Clinical and economical endpoints before and after implementation of the pre-hospital risk stratification tool will be compared to assess clinical benefit and cost-effectiveness.

Conclusion: The FAMOUS TRIAGE project is a triple phase study that aims to optimize the pre-hospital management of chest pain patients without ST-segment elevation by providing tools for pre-hospital identification of NSTEMI or exclusion of acute coronary syndrome at home.

Trial id: NTR4205. Dutch Trial Register [http://www.trialregister.nl]: trial number 4205.

Keywords: ACS; AMI; Acute coronary syndrome; FAMOUS TRIAGE; NSTEMI; UA; acute myocardial infarction; ambulance; chest pain; high-sensitive troponin; modified HEART score; non ST-elevation acute coronary syndrome; non ST-elevation myocardial infarction; nonSTEMI; paramedic; pre-hospital; risk stratification; triage; unstable angina.