Methods:

The ARTICA study is an investigator-initiated, multicenter, open-label, randomized controlled trial conducted at five ambulance regions in the Netherlands. All ambulance paramedics were instructed to calculate the HEAR score (History, Electrocardiogram, Age, and Risk factors) and perform point-of-care troponin measurements. The study population consisted of low-risk chest pain patients suspected of NSTE-ACS, who had onset of symptoms ≥2 hours before ambulance presentation. Patients were randomized to either the prehospital rule-out strategy or the emergency department (ED) rule-out strategy. In the prehospital rule-out strategy, patients underwent an on-site point-of-care (POC) troponin T measurement. If POC troponin T was low (<40 ng/L), the care for the patient was transferred to the general practitioner. If POC troponin T was elevated (≥40 ng/L), the patient was transported to the ED. In the ED rule-out strategy, patients were transferred directly to the ED for additional testing. Follow-up was performed at 30 days through telephone and email, with data collected on all health care resource use and productivity losses. Health care resource use data were collected for all randomized patients, with costs determined according to the 2018 reference list of the Dutch National Healthcare Institute. The primary outcome was health care costs at 30 days. The secondary outcome was the incidence of MACE at 30 days.