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. 2024 Oct 8;41(5):832-840.
doi: 10.1093/fampra/cmae028.

Telephone triage of chest pain in out-of-hours primary care: external validation of a symptom-based prediction rule to rule out acute coronary syndromes

Amy Manten  1   2   3 , Ralf E Harskamp  1   2   3 , Wim B Busschers  1 , Eric P Moll van Charante  1   2   3   4 , Jelle C L Himmelreich  1   2   3
Affiliations

Telephone triage of chest pain in out-of-hours primary care: external validation of a symptom-based prediction rule to rule out acute coronary syndromes

Amy Manten et al. Fam Pract. .

Abstract

Introduction: Telephone triage is pivotal for evaluating the urgency of patient care, and in the Netherlands, the Netherlands Triage Standard (NTS) demonstrates moderate discrimination for chest pain. To address this, the Safety First Prediction Rule (SFPR) was developed to improve the safety of ruling out acute coronary syndrome (ACS) during telephone triage.

Methods: We conducted an external validation of the SFPR using data from the TRACE study, a retrospective cohort study in out-of-hours primary care. We evaluated the diagnostic accuracy assessment for ACS, major adverse cardiovascular events (MACE), and major events within 6 weeks. Moreover, we compared its performance with that of the NTS algorithm.

Results: Among 1404 included patients (57.3% female, 6.8% ACS, 8.6% MACE), the SFPR demonstrated good discrimination for ACS (C-statistic: 0.79; 95%-CI: 0.75-0.83) and MACE (C-statistic: 0.79; 95%-CI: 0.0.76-0.82). Calibration was satisfactory, with overestimation observed in high-risk patients for ACS. The SFPR (risk threshold 2.5%) trended toward higher sensitivity (95.8% vs. 86.3%) and negative predictive value (99.3% vs. 97.6%) with a lower negative likelihood ratio (0.10 vs. 0.34) than the NTS algorithm.

Conclusion: The SFPR proved robust for risk stratification in patients with acute chest pain seeking out-of-hours primary care in the Netherlands. Further prospective validation and implementation are warranted to refine and establish the rule's clinical utility.

Keywords: acute coronary syndrome; chest pain; clinical prediction rule; primary care.

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Conflict of interest statement

None declared.

Figures

Figure 1.
Figure 1.
Flow of patients. The TRACE cohort comprised 1803 patients eligible for inclusion. Due to missing data on SFPR predictors or outcome measures, 399 patients were excluded from the final analyses. SFPR, Safety First Prediction Rule.
Figure 2.
Figure 2.
Calibration plot for the Safety First prediction rule for ACS. Brackets on the top horizontal axis indicate the proportion of patients with respective predicted risk (x axis).
Figure 3.
Figure 3.
Calibration plots of the Safety First Prediction Rule for MACE and major events. Brackets on the top horizontal axis indicate the proportion of patients with respective predicted risk (x axis). MACE, major adverse cardiac events.
Figure 4.
Figure 4.
Association between sex and age for the probability of ACS, MACE and major events in the TRACE cohort. ACS, acute coronary syndrome; MACE, major adverse cardiovascular events.
See this image and copyright information in PMC

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