New Research Could Provide Early Reassurance to Patients with Chest Pain and Reduce Stress on Ambulance Crews and A&E Departments

North West Ambulance NHS Trust paramedics in Greater Manchester are part of a major new research study to assess whether future patients who call 999 with chest pain can be safely assessed and managed by paramedics, without having to go to hospital. 

Paramedics from North West Ambulance Service NHS Trust (NWAS) are aiming to get more than 230 Greater Manchester patients to take part in the trial. Consenting patients are to be drawn from across central and north Manchester, Salford and Bolton.

The study is being led by the University of Manchester and Manchester University NHS Foundation Trust (MFT) and funded by the National Institute for Health Research (NIHR). Three other ambulance services nationally will also be involved, with a total of 700 patients expected to participate across three regions. 

The study, titled PRESTO (the Pre-hospital Evaluation of Sensitive Troponin), is part of the NHS’ ambition to find new ways of delivering healthcare more efficiently without the need for hospital treatment.

Chest pain is the second most common reason why people call 999 for an ambulance. However, the symptoms associated with a heart attack and those of non-cardiac conditions are often similar. These patients are routinely taken to A&E for tests, although ultimately most do not have a health problem that needs treatment in a hospital.

The study aims to see if the NHS can safely avoid many of these unnecessary hospital attendances, thereby reducing stress for patients and easing pressure on A&E departments and ambulances services, which usually come under the greatest stress during the winter months.

All participants in the study will see no difference to their standard care or diagnosis. 

Angela Foulkes from South Manchester suffered a heart attack 26 years ago after months of experiencing strange sensations around her neck.

Late one evening, and with no diagnosis of cardiac problems, Mrs Foulkes and her husband called the out-of-hours GP, who examined her, then called for an ambulance to take her to hospital.

It was established that Mrs Foulkes had suffered a heart attack and she was later diagnosed with angina, but she has since lived comfortably with her condition.  

She was invited to be a patient representative on the PRESTO steering group, having been involved with HeartHelp Support Group in Withington since her episode.

Mrs Foulkes, who worked with children with hearing impairments before retirement, said:

“Patients value rapid, accurate information about their condition. PRESTO promises good for patients and good for the NHS.”

Steve Bell, Consultant Paramedic and Principal Investigator at the North West Ambulance Service, said: 

“At North West Ambulance Service, we are delighted to be at the forefront of this clinical study to evaluate a new innovative way of working to benefit patients experiencing chest pain.” 

“This new technique allows us to undertake more in-depth tests for patients at home, meaning clinicians can make more informed decisions about the best care for the patient.”

“This could mean that future patients who don’t require immediate hospital treatment can be safely cared for in the community, reducing unnecessary A&E admissions and saving vital emergency resources.”

“We are conducting the trial with paramedics and emergency medical technicians across Greater Manchester, with patients matching the criteria being given the opportunity to be a part of this significant project.” 

How does PRESTO work?

Researchers have already developed a system called the ‘Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid’ to avoid unnecessary hospital admissions from A&E. The PRESTO study is now assessing whether this decision aid is suitable for use before patients are taken to hospital.

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T-MACS calculates how likely it is that a patient has a serious heart problem by considering their symptoms and the results of basic tests. Research has shown that T-MACS can safely reduce unnecessary hospital admissions, enabling immediate reassurance for almost half of all patients having tests. It has been successfully used in practice in Manchester since June 2016.

The blood tests used in T-MACS can now be carried out using portable devices and could become standard procedure in ambulances, avoiding many unnecessary transfers to hospital. The PRESTO study will help researchers understand whether T-MACS remains accurate inside the portable ambulance setting.

Rick Body, Professor of Emergency Medicine at Manchester Royal Infirmary, part of Manchester University NHS Foundation Trust,  and Chief Investigator of the study, said:

“Every year the pressure on Emergency Departments increases, and that leads to patients having to wait longer in what are often very stressful situations. Our research has already helped to reduce the time that patients with chest pain must stay in hospital for tests.”

“Paramedics are highly skilled professionals but, until now, they simply haven’t had the equipment they need to be sure if patients have serious heart problems. That means that patients with chest pain are routinely taken to hospital for tests, which is inconvenient for patients and inefficient for the NHS.”

“If we can now use portable blood testing devices to run those important tests without patients having to come to the hospital, the impact would be huge. Patients who don’t have serious heart problems could receive almost immediate reassurance with minimal impact on their lives. Ambulances could respond faster to people who most need their help. Emergency Departments will be less crowded, which will help to reduce waiting times.”

“Patients who agree to take part in the study will see no difference to their standard care or diagnosis, but will just have a few additional tests and observations to help us to calculate the accuracy of T-MACS and its suitability for use in ambulances.”

Researchers are looking to recruit patients who call 999 with a complaint of chest pain and are subsequently attended by the ambulance service. After obtaining consent and providing the necessary treatment for the patient, paramedics will draw a blood sample in the ambulance, comprehensively assess a heart tracing, and record patients’ symptoms including details relating to the T-MACS.

Investigators will review the patients’ medical records after 30 days to find out the final diagnosis. The actual care given to patients will not differ from today’s standard care. But the data generated throughout the course of the study will allow researchers to calculate the accuracy of T-MACS and its suitability for standardised use in by ambulance paramedics.

The study is supported by the NIHR Clinical Research Network: Greater Manchester and receiving in kind support from Abbott Point of Care, LumiraDx and Roche Diagnostics International Ltd.