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TOPLINE
Among patients presenting with acute chest pain in primary care, a diagnostic approach combining the Marburg Heart Score (MHS) with finger-prick high-sensitivity cardiac troponin I (hs-cTnI) point-of-care testing showed high sensitivity for acute coronary syndrome (ACS) and myocardial infarction.
METHODOLOGY
- Researchers conducted a cluster-randomised trial across Dutch primary care practices between August 2021 and February 2024 to test whether a clinical decision rule combining the MHS and point-of-care troponin test could safely rule out ACS or myocardial infarction.
- They randomly assigned practices to the intervention or the control group (usual care). Intervention practices applied the clinical decision rule combining the MHS (a five-item clinical score comprising age and sex, prior cardiovascular disease, patient attribution, chest pain worsened by physical activity, and no pain when pressing on the area) with a finger-prick hs-cTnI measurement (a turnaround time of approximately 8 minutes; diagnostic cutoff ≤ 3.8 ng/L).
- The clinical decision rule yielded three recommendations on the basis of the MHS and hs-cTnI levels:
- ACS could be ruled out, and reassurance with monitoring was advised.
- ACS could not be excluded and prompted cardiology consultation.
- The risk for ACS was elevated, and immediate emergency department referral was indicated.
- The researchers included adult patients presenting with acute chest pain at 66 practices in the analysis: 740 patients in the intervention group and 87 in the control group; the mean age was 60 years in both groups, with women comprising 53% of the intervention group and 52% of the control group.
- Primary outcomes were the diagnostic performance of the clinical decision rule at the first consultation (sensitivity, specificity, and negative and positive predictive values) for ACS and myocardial infarction and emergency department referral rates compared with usual care. Major adverse cardiac events (MACEs) were also assessed at 6 weeks and 6 months.
TAKEAWAY
- The clinical decision rule applied by GPs achieved a sensitivity of 98.3% (95% CI, 90.8%-100%) and a specificity of 49.1% (95% CI, 45.3%-52.9%), with a negative predictive value of 99.7% (95% CI, 98.0%-100%).
- For myocardial infarction specifically, the clinical decision rule achieved a sensitivity of 100% (95% CI, 92.6%-100%) and a specificity of 48.6% (95% CI, 44.8%-52.4%), with a negative predictive value of 100% (95% CI, 98.9%-100%).
- Overall, 45.4% of patients in the intervention group were not referred to the emergency department (classified as those at low risk); among them, 1.2% experienced MACEs by 6 weeks, and among those with 6-month follow-up, 1.6% experienced MACEs.
- Emergency department referral rates did not differ significantly between the intervention and control groups (54.6% vs 47.1%; P = .39).
IN PRACTICE
"Standardizing CDR [clinical decision rule] use across pre-hospital and ED [emergency department] settings may improve communication between healthcare providers and overall care quality. Successful implementation will require assessment of facilitators and barriers to change established work routines," the researchers wrote.
SOURCE
The study was led by Simone van den Bulk, MD, Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands. It was published online on September 10, 2026, in the British Journal of General Practice.
LIMITATIONS
The trial did not enrol as many patients as planned, especially in the control group, which made it harder to identify real differences in how many patients were referred to specialists and limited the ability to assess the diagnostic performance in the control group and specific patient subgroups. One third of the participants in the control group underwent laboratory testing for high-sensitivity troponin, despite guidelines advising against it. Although this may have reduced referrals, it demonstrated that GPs use this test in practice. Data were not collected for patients who were excluded from the study or for patients with chest pain in whom GPs did not suspect ACS.
DISCLOSURES
This study was supported by ZonMw. The Atellica VTLi immunoassay analysers used for the hs-cTnI point-of-care testing were supplied by Siemens Healthineers. The authors reported no relevant conflicts of interest.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
