References

Abbott. i-STAT1: a handheld blood analyzer that delivers lab-quality, diagnostic results in minutes. 2022. https://www.pointofcare.abbott/int/en/offerings/istat/istat-handheld (accessed 23 February 2022)

Ahmed S, Khan A, Ali SI Differences in symptoms and presentation delay times in myocardial infarction patients with and without diabetes: a cross-sectional study in Pakistan. Indian Heart J. 2018; 70:(2)241-245 https://doi.org/10.1016/j.ihj.2017.07.013

Alghamdi A, Cook E, Carlton E PRe-hospital Evaluation of Sensitive TrOponin (PRESTO) study: multicentre prospective diagnostic accuracy study protocol. BMJ Open. 2019; 9:(10) https://doi.org/10.1136/bmjopen-2019-032834

Arora S., Matsushita K, Qamar A Early versus late percutaneous revascularization in patients hospitalized with non ST-segment elevation myocardial infarction: the atherosclerosis risk in communities surveillance study. Catheter Cardiovasc Interv. 2018; 91:(2)253-259 https://doi.org/10.1002/ccd.27156

Arslan M, Dedic A, Boersma E, Dubois EA. Serial high-sensitivity cardiac troponin T measurements to rule out acute myocardial infarction and a single high baseline measurement for swift rule-in: a systematic review and meta-analysis. Eur Heart J Acute Cardiovasc Care. 2019; 9:(1)14-22 https://doi.org/10.1177/2048872618819421

Austin M, Sinclair J, Leduc S Evaluation of outcomes after implementation of a provincial prehospital bypass standard for trauma patients—an Eastern Ontario experience. Canadian Journal of Emergency Medicine. 2019; 21:(1)65-66 https://doi.org/10.1017/cem.2019.199

Bingisser R, Cairns C, Christ M Cardiac troponin: a critical review of the case for point-of-care testing in the ED. Am J Emerg Med. 2012; 30:(8)1639-1649 https://doi.org/10.1016/j.ajem.2012.03.004

Body R, Carley S, Wibberley C The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation. 2010; 81:(3)281-286 https://doi.org/10.1016/j.resuscitation.2009.11.014

Canto JG, Shlipak MG, Rogers CJ Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA. 2000; 283:(24)3223-3229 https://doi.org/10.1001/jama.283.24.3223

Chacko S, Haseeb S, Glover BM, Wallbridge D, Harper A. The role of biomarkers in the diagnosis and risk stratification of acute coronary syndrome. Future Sci OA. 2018; 4:(1) https://doi.org/10.4155/fsoa-2017-0036

Chapman D. Advanced search features of PubMed. J Can Acad Child Adolesc Psychiatr. 2009; 18:(1)58-59

Chapman AR, Stewart S, Mills NL. Contemporary point of care cardiac troponin testing in suspected acute coronary syndrome. Heart. 2019; 105:(10)740-741 https://doi.org/10.1136/heartjnl-2018-314306

Chen YL, Wang R, He Y [Value of evaluating the coronary collateral circulation by transluminal attenuation gradient in patients with chronic total occlusion and related influencing factors] (article in Chinese). Zhonghua Xin Xue Guan Bing Za Zhi. 2017; 45:(10)857-861 https://doi.org/10.3760/cma.j.issn.0253-3758.2017.10.009

Dahlgren BE, Hogberg R, Nilsson HG. Portable, but suitable: devices in prehospital care might be hazardous to patient or to aviation safety. Prehosp Disaster Med. 1997; 12:(1)64-57 https://doi.org/10.1017/S1049023X00037249

Docherty AB, Alam S, Shah AS Unrecognised myocardial infarction and its relationship to outcome in critically ill patients with cardiovascular disease. Intensive Care Med. 2018; 44:(12)2059-2069 https://doi.org/10.1007/s00134-018-5425-0

Faramand Z, Frisch SO, DeSantis A Lack of significant coronary history and ecg misinterpretation are the strongest predictors of undertriage in prehospital chest pain. J Emerg Nurs. 2019; 45:(2)161-168 https://doi.org/10.1016/j.jen.2018.10.007

Freynhofer MK, Tajsić M, Wojta J, Huber K. Biomarkers in acute coronary artery disease. Wien Med Wochenschr. 2012; 162:(21–22)489-498 https://doi.org/10.1007/s10354-012-0148-2

Gershlick AH, Banning AP, Myat A, Verheugt FW, Gersh BJ. Reperfusion therapy for STEMI: is there still a role for thrombolysis in the era of primary percutaneous coronary intervention?. Lancet. 2013; 382:(9892)624-632 https://doi.org/10.1016/S0140-6736(13)61454-3

Gibson CM. Time is myocardium and time is outcomes. Circulation. 2001; 104:(22)2632-2634 https://doi.org/10.1161/circ.104.22.2632

Gimenez MR, Twerenbold R, Boeddinghaus J Near-linearity of release of cardiac troponin in early acute myocardial infarction. Eur Heart J. 2017; 38 https://doi.org/10.1093/eurheartj/ehx502.P2711

Gu YL, Voors AA, Zijlstra F Comparison of the temporal release pattern of copeptin with conventional biomarkers in acute myocardial infarction. Clin Res Cardiol. 2011; 100:(12)1069-1076 https://doi.org/10.1007/s00392-011-0343-y

IJkema BB, Bonnier JJ, Schoors D, Schalij MJ, Swenne CA. Role of the ECG in initial acute coronary syndrome triage: primary PCI regardless presence of ST elevation or of non-ST elevation. Neth Heart J. 2014; 22:(11)484-490 https://doi.org/10.1007/s12471-014-0598-9

Juliano M, Wason C. Comparison of point-of-care versus laboratory troponin testing in an emergency department setting. Mil Med. 2017; 182:(7)e1938-e1940 https://doi.org/10.7205/MILMED-D-16-00387

Keller T, Tzikas S, Zeller T Copeptin improves early diagnosis of acute myocardial infarction. J Am Coll Cardiol. 2010; 55:(19)2096-2106 https://doi.org/10.1016/j.jacc.2010.01.029

Reducing avoidable ambulance conveyance in England: interventions and associated evidence. Prepared for NHS England and NHS Improvement. 2020. https://tinyurl.com/2yz3nkmr (accessed 23 February 2023)

Li F, Clark R, Versance V The association between point-of-care testing of troponin and the management of patients with chest pain suspected of acute coronary syndrome: a systematic review protocol. JBI Database System Rev Implement Rep. 2014; 12:(3)99-112 https://doi.org/10.11124/jbisrir-2014-1521

Liang C, Liu Y, Niu A, Liu C, Li J, Ning D. Smartphone-app based point-of-care testing for myocardial infarction biomarker cTnI using an autonomous capillary microfluidic chip with self-aligned on-chip focusing (SOF) lenses. Lab Chip. 2019; 19:(10)1797-1807 https://doi.org/10.1039/C9LC00259F

Lipinski MJ, Escárcega RO, D'Ascenzo F A systematic review and collaborative meta-analysis to determine the incremental value of copeptin for rapid rule-out of acute myocardial infarction. Am J Cardiol. 2014; 113:(9)1581-1591 https://doi.org/10.1016/j.amjcard.2014.01.436

Loewenstein D, Stake C, Cichon M. Assessment of using fingerstick blood sample with i-STAT point-of-care device for cardiac troponin I assay. Am J Emerg Med. 2013; 31:(8)1236-1239 https://doi.org/10.1016/j.ajem.2013.04.031

Lotze U, Lemm H, Heyer A, Müller K. Combined determination of highly sensitive troponin T and copeptin for early exclusion of acute myocardial infarction: first experience in an emergency department of a general hospital. Vasc Health Risk Manag. 2011; 7:509-515 https://doi.org/10.2147/VHRM.S21753

Marcolino MS, Ribeiro AL. Focusing on prehospital care to improve ST elevation myocardial infarction care. Heart. 2019; 106:(5)323-324 https://doi.org/10.1136/heartjnl-2019-315475

McCoy J, Eisenstein R, Hui C Point-of-care testing vs laboratory testing during high patient volume situations. Open Journal of Emergency Medicine. 2019; 7:(4)49-56 https://doi.org/10.4236/ojem.2019.74006

Möckel M, Searle J. Copeptin-marker of acute myocardial infarction. Curr Atheroscler Rep. 2014; 16:(7) https://doi.org/10.1007/s11883-014-0421-5

Morawiec B, Kawaecki D, Przywars-Chowaniec B Copeptin as a prognostic marker in acute chest pain and suspected acute coronary syndrome. Dis Markers. 2018; 2018 https://doi.org/10.1155/2018/6597387

Myocardial Ischaemia National Audit Project. How the NHS cares for patients with heart attack. Annual public report April 2014-March 2015. 2017. https://tinyurl.com/ytatbzu2 (accessed 23 February 2022)

Nagesh CM, Roy A. Role of biomarkers in risk stratification of acute coronary syndrome. Indian J Med Res. 2010; 132:(5)627-433 https://doi.org/10.4103/0971-5916.73419

National Institute for Health and Care Excellence. Myocardial infarction with ST-segment elevation: acute management. Clinical guideline [CG167]. 2013. https://www.nice.org.uk/guidance/cg167 (accessed 23 February 2022)

Nickel CH, Bingisser R, Morgenthaler NG. The role of copeptin as a diagnostic and prognostic biomarker for risk stratification in the emergency department. BMC Med. 2012; 10 https://doi.org/10.1186/1741-7015-10-7

Nour S, Plourde G. Pharmacoepidemiology in the prevention of adverse drug reactions. 2019; 25-65 https://doi.org/10.1016/B978-0-12-816183-8.00003-2

Paradies V, Chan MHH, Hausenloy DJ. Chapter 22. Strategies for reducing myocardial infarct size following STEMI. In: Watson TJ, Ong PJL, Tcheng JE (eds). Singapore: Springer; 2018 https://doi.org/10.1007/978-981-13-1114-7_22

Pedersen CK, Stengaard C, Søndergaard H A multicentre, randomized, controlled open-label trial to compare an Accelerated Rule-Out protocol using combined prehospital copeptin and in-hospital high sensitive troponin with standard rule-out in patients suspected of acute Myocardial Infarction—the AROMI trial. Trials. 2018; 19:(1) https://doi.org/10.1186/s13063-018-2990-z

Pedersen CK, Stengaard C, Friesgaard K Chest pain in the ambulance; prevalence, causes and outcome—a retrospective cohort study. Scand J Trauma Resusc Emerg Med. 2019; 27:(1) https://doi.org/10.1186/s13049-019-0659-6

Raskovalova T, Twerenbold R, Collinson PO Diagnostic accuracy of combined cardiac troponin and copeptin assessment for early rule-out of myocardial infarction: a systematic review and meta-analysis. Eur Heart J Acute Cardiovasc Care. 2014; 3:(1)18-27 https://doi.org/10.1177/2048872613514015

Rasmussen MB, Stengaard C, Sørensen JT Predictive value of routine point-of-care cardiac troponin T measurement for prehospital diagnosis and risk-stratification in patients with suspected acute myocardial infarction. Eur Heart J Acute Cardiovasc Care. 2019; 8:(4)299-308 https://doi.org/10.1177/2048872617745893

Reichlin T, Hochholzer W, Bassetti S Early diagnosis of myocardial infarction with sensitive cardiac troponin assays. N Engl J Med. 2009; 361:(9)858-867 https://doi.org/10.1056/NEJMoa0900428

Reinstadler SJ, Klug G, Feistritzer HJ, Metzler B, Mair J. Copeptin testing in acute myocardial infarction: ready for routine use?. Dis Markers. 2015; 2015 https://doi.org/10.1155/2015/614145

Roffi M, Patrono C, Collet J-P 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016; 37:(3)267-315 https://doi.org/10.1093/eurheartj/ehv320

Shin H, Jang BH, Lim TH Diagnostic accuracy of adding copeptin to cardiac troponin for non-ST-elevation myocardial infarction: a systematic review and meta-analysis. PLoS One. 2018; 13:(7) https://doi.org/10.1371/journal.pone.0200379

Slagman A, Searle J, Müller C, Möckel M. Temporal release pattern of copeptin and troponin T in patients with suspected acute coronary syndrome and spontaneous acute myocardial infarction. Clin Chem. 2015; 61:(10)1273-1282 https://doi.org/10.1373/clinchem.2015.240580

Stengaard C, Sørensen JT, Ladefoged SA The potential of optimizing prehospital triage of patients with suspected acute myocardial infarction using high-sensitivity cardiac troponin T and copeptin. Biomarkers. 2017; 22:(3–4)351-360 https://doi.org/10.1080/1354750X.2016.1265008

Suzuki K, Komukai K, Nakata K The usefulness and limitations of point-of-care cardiac troponin measurement in the emergency department. Internal Medicine. 2018; 57:(12)1673-1680 https://doi.org/10.2169/internalmedicine.0098-17

Terkelsen CJ, Sørensen JT, Maeng M System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention. JAMA. 2010; 304:(7)763-771 https://doi.org/10.1001/jama.2010.1139

Wu AB. Release of cardiac troponin from healthy and damaged myocardium. Frontiers in Laboratory Medicine. 2017; 1:(3)144-150 https://doi.org/10.1016/j.flm.2017.09.003

Xu RY, Zhu XF, Yang Y, Ye P. High-sensitive cardiac troponin T. J Geriatr Cardiol. 2013; 10:(1)102-109 https://doi.org/10.3969/j.issn.1671-5411.2013.01.015

pre-hospital
patient care
innovation
evidence
clinical skills

Prehospital point-of-care biomarkers: missing link in acute myocardial infarction?

02 March 2022
Features
02 March 2022
Volume 14 · Issue 3

Abstract

Coronary heart disease is a leading cause of death worldwide. Paramedics are instrumental in the treatment, triage and transport of patients experiencing acute coronary syndromes and acute myocardial infarction (AMI). Paramedics currently rely on prehospital electrocardiography and patient symptomology to diagnose AMI, which may result in missed diagnoses. Point-of-care biomarkers such as cardiac troponin (cTnT) and copeptin may have the potential to increase the diagnostic capabilities of prehospital providers. Multiple electronic databases (MAG Online Library, Cochrane Library, PubMed and Embase) were searched to evaluate the feasibility and potential application of cardiac biomarkers cTnT and copeptin in the prehospital setting. Because of the paucity of evidence, this article explores the evidence on the dual-marker strategy of cTnT and copeptin to increase diagnostic capabilities of prehospital providers, and as an adjunct for decision-making and risk stratification for AMI. The evidence suggests that using the combined dual-marker strategy of cTnT and copeptin may counteract limitations of the ‘troponin-blind’ period of cTnT and the low cardiac specificity of copeptin. However, the research for this method is still in its infancy and requires investigation into its feasibility and affordability as well as into the training required to implement it in paramedic practice.

The prehospital landscape is unrecognisable from how it was 30 years ago and could be poised for a dramatic shift towards rapid diagnostic capabilities for paramedics, with point-of-care (PoC) biomarker testing.

The challenge for paramedic practice is its heavy reliance upon prehospital electrocardiography and patient symptomology to diagnose acute myocardial infarction (AMI), which may delay treatment and definitive care (Chacko et al, 2018). PoC cardiac biomarkers could be the missing link to resolve diagnostic uncertainties of AMI and subsequent decision-making in paramedic practice (Pedersen et al, 2019).

This article explores and discusses the value of introducing PoC dual-marker testing (cardiac troponin-T (cTnT) and copeptin) as an adjunct to aid diagnosis and decision-making for treatment and triage of AMI in UK paramedic practice. The cost-effectiveness, feasibility and the future of this technology will also be discussed.

Preliminary searching of the extent of the literature determined that the body of evidence surrounding cardiac biomarkers in the prehospital setting was limited. Because the literature was so sparse, a generalised exploration of the literature was performed to evaluate the feasibility and potential application of cardiac biomarkers in the prehospital setting.

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Acute myocardial infarction
Biomarkers
Cardiac troponin
Copeptin
Point-of-care testing
Prehospital diagnosis
Cardiology