FAST-ED scale for prehospital triage of large vessel occlusion: results in the field

 

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Abstract

Background Acute ischemic stroke (AIS) is an extremely time-sensitive condition. The field triage of stroke patients should consider a careful balance between the best destination for the timely delivery of intravenous and/or endovascular reperfusion therapies. The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale has been shown to have an accuracy comparable to that of the National Institutes of Health Stroke Scale (NIHSS). However, it has not been tested in the field.

Objective To evaluate the accuracy of the FAST-ED scale in the detection of AIS due to large vessel occlusion (LVO) in the prehospital setting.

Methods A cross-sectional study of consecutive prospective data collected from February 2017 to May 2019 in the city of Porto Alegre, state of Rio Grande do Sul, Southern Brazil, correlating the prehospital FAST-ED scale scores with the hospital diagnosis of LVO. Area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated.

Results In total, 74 patients were included in the analysis. As compared with the diagnosis of LVO upon hospital discharge, the prehospital FAST-ED scale applied by paramedics had a sensitivity of 80%, a specificity of 47.7%, a PPV of 51.1%, an NPV of 77.8%, and an AUC of 0.68 (95% confidence interval [95%CI]: 0.55–0.80). Among the patients with a final diagnosis of AIS, the accuracy was higher, with an AUC of 0.75 (95%CI: 0.60–0.89), a sensitivity of 80%, a specificity of 60%, a PPV of 80%, and an NPV of 60%.

Conclusions In the present study, the FAST-ED scale, which was applied by paramedics in the field, demonstrated moderate accuracy but high sensitivity and NPV, which are essential attributes for a triage scale. While larger studies are still needed, these findings further support the use of the FAST-ED in stroke triage.

Resumo

Antecedentes O acidente vascular cerebral isquêmico (AVCI) é uma doença altamente dependente do tempo. A triagem de pacientes com AVCI na cena deve considerar um equilíbrio cuidadoso entre o melhor destino para a administração rápida de terapias de reperfusão intravenosas e/ou endovasculares. Já foi demonstrado que a escala de Avaliação de campo de triagem de AVC para destino de emergência (Field Assessment Stroke Triage for Emergency Destination, FAST-ED, em inglês) tem precisão comparável à da Escala de AVC dos Institutos Nacionais de Saúde dos Estados Unidos (National Institutes of Health Stroke Scale, NIHSS, em inglês). Entretanto, a FAST-ED não foi testada em campo.

Objetivo Avaliar a acurácia da escala FAST-ED na detecção de AVCI por oclusão de grande vaso (OGV) no contexto pré-hospitalar.

Métodos Estudo transversal de dados prospectivos consecutivos, coletados de fevereiro de 2017 a maio de 2019, em Porto Alegre, Rio Grande do Sul, Brasil, em que se correlacionam a pontuação pré-hospitalar na escala FAST-ED e o diagnóstico hospitalar de OGV. A área sob a curva (ASC), a sensibilidade, a especificidade, o valor preditivo positivo (VPP), e o valor preditivo negativo (VPN) foram calculados.

Resultados Ao todo, 74 pacientes foram incluídos na análise. Comparada ao diagnóstico de OGV na alta hospitalar, a escala FAST-ED aplicada em campo por profissionais do pré-hospitalar teve sensibilidade de 80%, especificidade de 47,7%, VPP de 51,1%, VPN de 77,8%, e ASC de 0,68 (intervalo de confiança de 95% [IC95%]: 0,55–0,80). Entre pacientes com diagnóstico final de AVCI, a precisão foi mais alta, com ASC de 0,75 (IC95%: 0,60–0,89), sensibilidade de 80%, especificidade de 60%, VPP de 80%, e VPN de 60%.

Conclusões Neste estudo, a escala FAST-ED, aplicada por profissionais do pré-hospitalar em campo, demonstrou precisão moderada, com alta sensibilidade e VPN, atributos essenciais para uma escala de triagem. Embora estudos com amostras maiores ainda sejam necessários, estes achados apoiam o uso da FAST-ED na triagem de AVCI.

Authors' Contributions

LAC: conceptualization, methodology, investigation, formal analysis, data curation, writing – first draft, project administration; ACS: methodology, investigation, writing – first draft; MSR, MDM: investigation, data curation, writing – review; RGN: conceptualization, methodology, writing – review; SCOM: conceptualization, investigation, methodology data curation, writing – review.

This article is a result of the theses for achievement of the Master‧s Degree in Medicine – Medical Sciences at Universidade Federal do Rio Grande do Sul.[1]

Publication History

Received: 22 April 2021

Accepted: 16 November 2021

Article published online:
04 October 2022

© 2022. Academia Brasileira de Neurologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit (https://creativecommons.org/licenses/by/4.0/)

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• References

• 1 Carbonera LA. Validação do aplicativo FAST-ED na triagem pré-hospitalar de oclusão de grande vaso em pacientes com acidente vascular cerebral isquêmico. 2019. 40 f. Dissertação (Mestrado) – Curso de Medicina – Ciências Médicas, Universidade Federal do Rio Grande do Sul, Porto Alegre, 2019. Disponível em: https://www.lume.ufrgs.br/handle/10183/206562. Acesso em: 03 ago. 2022
  Google Scholar
• 2 Caplan LR. Basic Pathology, Anatomy, and Pathophysiology of Stroke. In: Caplan's Stroke. Elsevier; pp. 22-63
  Google Scholar
• 3 Lima FO, Mont'Alverne FJA, Bandeira D, Nogueira RG. Pre-hospital Assessment of Large Vessel Occlusion Strokes: Implications for Modeling and Planning Stroke Systems of Care. Front Neurol 2019; 10: 955 Epub ahead of print DOI: 10.3389/fneur.2019.00955.
  CrossrefPubMedGoogle Scholar
• 4 Berkhemer OA, Fransen PSS, Beumer D. et al; MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015; 372 (01) 11-20
  CrossrefPubMedGoogle Scholar
• 5 Campbell BCV, Mitchell PJ, Kleinig TJ. et al; EXTEND-IA Investigators. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015; 372 (11) 1009-1018
  CrossrefPubMedGoogle Scholar
• 6 Goyal M, Demchuk AM, Menon BK. et al; ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015; 372 (11) 1019-1030
  CrossrefPubMedGoogle Scholar
• 7 Jovin TG, Chamorro A, Cobo E. et al; REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015; 372 (24) 2296-2306
  CrossrefPubMedGoogle Scholar
• 8 Saver JL, Goyal M, Bonafe A. et al; SWIFT PRIME Investigators. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015; 372 (24) 2285-2295
  CrossrefPubMedGoogle Scholar
• 9 Powers WJ, Rabinstein AA, Ackerson T. et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; 50 (12) e344-e418
  CrossrefPubMedGoogle Scholar
• 10 Zhelev Z, Walker G, Henschke N, Fridhandler J, Yip S. Prehospital stroke scales as screening tools for early identification of stroke and transient ischemic attack. Cochrane Database Syst Rev 2019; 4: CD011427 ; Epub ahead of print DOI: 10.1002/14651858.CD011427.pub2.
  CrossrefPubMedGoogle Scholar
• 11 Pérez de la Ossa N, Carrera D, Gorchs M. et al. Design and validation of a prehospital stroke scale to predict large arterial occlusion: the rapid arterial occlusion evaluation scale. Stroke 2014; 45 (01) 87-91
  CrossrefPubMedGoogle Scholar
• 12 Katz BS, McMullan JT, Sucharew H, Adeoye O, Broderick JP. Design and validation of a prehospital scale to predict stroke severity: Cincinnati Prehospital Stroke Severity Scale. Stroke 2015; 46 (06) 1508-1512
  CrossrefPubMedGoogle Scholar
• 13 Lima FO, Silva GS, Furie KL. et al. Field Assessment Stroke Triage for Emergency Destination: A Simple and Accurate Prehospital Scale to Detect Large Vessel Occlusion Strokes. Stroke 2016; 47 (08) 1997-2002
  CrossrefPubMedGoogle Scholar
• 14 Nogueira RG, Silva GS, Lima FO. et al. The FAST-ED App: A Smartphone Platform for the Field Triage of Patients With Stroke. Stroke 2017; 48 (05) 1278-1284
  CrossrefPubMedGoogle Scholar
• 15 Puolakka T, Virtanen P, Kuisma M. et al. Validation of the FAST-ED score for prehospital identification of stroke patients with large-vessel occlusion and a comparison with the clinician's judgment. In: Abstracts. British Medical Journal Publishing Group; p. A4.3–A5
  CrossrefGoogle Scholar
• 16 Guillory BC, Gupta AA, Cubeddu LX, Boge LA. Can Prehospital Personnel Accurately Triage Patients for Large Vessel Occlusion Strokes?. J Emerg Med 2020; 58 (06) 917-921
  CrossrefPubMedGoogle Scholar
• 17 IBGE. Cidades e estados - Porto Alegre. https://www.ibge.gov.br/cidades-e-estados/rs/porto-alegre.html 2020 , accessed 19 November 2020)
  PubMedGoogle Scholar
• 18 Martins SO, Mont'Alverne F, Rebello LC. et al; RESILIENT Investigators. Thrombectomy for Stroke in the Public Health Care System of Brazil. N Engl J Med 2020; 382 (24) 2316-2326
  CrossrefPubMedGoogle Scholar