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Pre-hospital cardiac troponin testing to ‘rule out’ Acute Coronary Syndromes using point of care test.

Three Part Question

In [patients with suspected cardiac chest pain, who calls an ambulance], can [paramedics use troponin point of care test] to [safely ‘rule out’ Acute Coronary Syndromes in the pre-hospital emergency settings]?

Clinical Scenario

At 22:40 the ambulance service operation centre receives a call for a 56-year-old patient complaining of chest pain and an ambulance unit is dispatched to the patient. On paramedic arrival, the woman is found sitting on the floor beside her washing machine. She is alert and orientated and shows no evidence of diaphoresis. She has no previous medical history. The chest pain had self-resolved 5 minutes ago. On examination, she has a clear airway, respiration is shallow, talking in complete sentences; lung sounds clear in upper lobes, skin warm and not clammy. The electrocardiogram (ECG) recorded on the scene shows benign early repolarization with no other abnormalities. There are no other pertinent findings. Her vital signs are: respiratory rate 20/minute, heart rate 65 beats per minute, oxygen saturation 96% in air, blood pressure 124/62, blood glucose 67 mg/dl. She stated that she was sorting the laundry when she suddenly could not catch her breath, then the chest pain started. She got dizzy, sat down, and called 999 but is now feeling back to normal.

Search Strategy

MEDLINE (Ovid) 1946 - September Week 3 2017
EMBASE (Ovid) 1974 - 2017 September 29
[Emergency Medical Services/ or paramedic*.mp. or Emergency Medical Technicians/ OR Ambulance*.mp. OR ( OR OR (out of OR] AND [Acute Coronary Syndrome/ OR Myocardial Infarction/ OR Chest pain/ ] OR [Troponin I/ OR Troponin/]

(troponin I OR troponin T OR ctni OR cTnI) AND (Emergency Medical Services OR Emergency Medical Technicians OR paramedic* OR pre-hospital OR prehospital OR ambulance* OR out of hospital OR out-of-hospital) AND (acute coronary syndrome OR Myocardial Infarction OR Chest Pain )

Search Outcome

The initial search and cross-referencing total of 273 papers were identified 10 papers (8 studies) of were relevant to the three-part question and the rest 263 were considered to be irrelevant or insufficient quality of evidence. We removed articles not written in English, which were published before the year 2000 (the first year when cardiac troponin was cited as the reference standard biomarker for diagnosing AMI) or where only the abstract was published.