Safety and efficiency of the HEART-GP strategy with point-of-care high-sensitivity troponin testing for acute chest pain in out-of-hours primary care: a prospective multicentre diagnostic accuracy study
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Background
GPs are often the first clinicians to assess acute chest pain in gatekeeper healthcare systems, but usually with limited diagnostic support. They must distinguish conditions that can be managed safely in primary care from those requiring immediate hospital evaluation, particularly acute coronary syndrome (ACS), while avoiding unnecessary over-referral to already pressured emergency departments. We evaluated HEART-GP, a novel GP-led strategy combining structured clinical assessment, fingerstick point-of-care high-sensitivity troponin I testing, and ECG when available.
Methods
We performed a prospective, multicentre, paired diagnostic accuracy study in four Dutch out-of-hours primary care centres implementing the HEART-GP strategy. Patients with acute non-traumatic chest pain and possible ACS according to the treating GP were enrolled from March 2023 to August 2025. Before troponin results were available, GPs recorded intended management, allowing paired comparison with unaided clinical judgement. The HEART-GP strategy recommended urgent referral for high clinical suspicion, troponin of >=4 ng/L, or ischaemic ECG. The primary outcome was adjudicated 6-week major adverse cardiovascular events (MACE). The study was registered as ISRCTN11954040 .
Findings
Of 1104 patients who underwent HEART-GP, 917 were included. MACE occurred in 62 (6.8%) and myocardial infarction in 52 (5.7%). HEART-GP classified 478 (52.1%) as low risk. For MACE, sensitivity was 95.2% (95% CI 86.5-99.0) and negative predictive value was 99.4% (98.1-99.8); three MACE occurred in the low-risk group, with no cardiac deaths. For myocardial infarction, sensitivity was 98.1% (89.7-100) and negative predictive value was 99.8% (98.6-100). Compared with unaided GP judgement, HEART-GP improved sensitivity for MACE (95.2% vs 67.7%; p<0·001) and myocardial infarction (98.1% vs 67.3%; p<0.001), and reduced urgent referrals (439 [47.9%] vs 483 [52.7%]; p=0.042).
Interpretation
HEART-GP showed high rule-out safety and may support GP diagnostic certainty and efficient referrals in patients with possible ACS. Implementation requires training, governance, safety-netting, and local pathways.
Funding
Dutch Heart Foundation. Siemens Healthineers provided in-kind device support and had no role in the trial design, conduct or interpretation.
Research in context
Evidence before this study
Acute chest pain is a common and high-stakes reason for urgent primary care assessment and is the cardinal symptom of acute coronary syndrome. In Dutch out-of-hours primary care, acute chest pain accounts for more than 160,000 contacts annually, or about 9 per 1000 inhabitants. Acute coronary syndrome is ultimately diagnosed in only about 5% of urgent primary care chest pain presentations, but missed cases can be life-threatening; previous primary care studies suggest that 8-19% of ACS cases are not recognised at first assessment. GPs are aware that clinical judgement alone does not reliably meet the very low miss rate considered acceptable for ruling out ACS (around 2–3% in previous work) and therefore often maintain a low threshold for urgent referral despite limited diagnostic support.
Added value of this study
This prospective multicentre study evaluated HEART-GP, a GP-led strategy that combines routine clinical assessment with a single fingerstick high-sensitivity cardiac troponin I point-of-care test and ECG findings when available. The HEART-GP strategy showed high rule-out safety, with sensitivity of 95% for major adverse cardiovascular events and 98% for myocardial infarction, and negative predictive values exceeding 99%. Compared with unaided GP assessment, the strategy improved detection of both outcomes while classifying a larger proportion of patients as low risk.
Implications of all available evidence
HEART-GP may support safer and more efficient assessment of acute chest pain in out-of-hours primary care by helping GPs identify patients who need immediate hospital evaluation and those who may not require urgent referral. Its observed miss rate approaches the low threshold that GPs have previously indicated as acceptable for ruling out ACS, but the strategy should remain focused on patients in whom ACS is clinically possible but not obvious. Implementation will require training, quality assurance, clear referral pathways, and safety-netting, and further research should assess external validation, cost-effectiveness, patient experience, and effects on ambulance use, emergency department burden, and downstream testing.
