Pre-hospital risk stratification using a modified thrombolysis in myocardial infarction score: a retrospective medical record review


Introduction:Paramedics commonly convey patients with non-ST elevation acute coronary syndrome (NSTEACS) to emergency departments (EDs) where a risk stratification model (RSM) determines the risk of death or adverse cardiovascular events, and thus whether the patient should be transferred to a specialist heart attack centre (HAC) for an invasive procedure. If paramedics were to risk-stratify the patients in the pre-hospital environment using a modified thrombolysis in myocardial infarction (MTIMI) RSM, this could result in primary triage to an appropriate hospital.Methods:A retrospective medical record review was completed using patients from a metropolitan ambulance service, one ED and one HAC comparing the current method of identifying high risk NSTEACS with a new method; the MTIMI RSM. Positive predictive value, negative predictive value, logistic regression and receiver operating statistic area under the curve (c-statistic) were used to compare methods.Results:Notes of 108 patients were used in this study. Current practice produced a c-statistic (c) of 0.73 (95% CI 0.62 to 0.85) and the MTIMI RSM (c=0.72, CI 0.61 to 0.83). The best RSM overall was the abbreviated MTIMI RSM with only three variables identified through logistic regression (c=0.79, 0.68 to 0.89).Conclusions:Both methods of identifying high-risk NSTEACS were similar as they both used the ECG variable, which was approximately twelve times more prognostic than any other variable. The need to identify a pre-hospital RSM with a good prognostic power still exists; therefore, other RSMs should be explored in a prospective study.

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