Kriterien der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung e. V. für „Brustschmerz-Ambulanzen“

[Comparison between chest pain units and stroke units : Essential components of the vascular emergency care system: comparison of structure, certification process, quality benchmarking and reimbursement]

BACKGROUND

Chest pain units (CPU) and stroke units (SU) have both become established as essential components of clinical emergency care. For both instances dedicated certification processes are installed. Up to summer 2020, 290 CPUs and 335 SUs have been successfully certified.

OBJECTIVE

The aim of this review is to compare the structures and the current certification situation of CPUs and SUs. Also, the younger CPU certification process is compared to the long established SU certification standard.

MATERIAL UND METHODS

The comparison includes the historical background, the certification process, quality benchmarking, possible additive structures, the current status of certification in Germany, the transfer of the concept to the European level as well as reimbursement issues.

RESULTS

Both certification concepts show clear analogies. Evidence for SUs is supported by a positive Cochrane analysis and for CPUs there are many studies from the German CPU registry. The main differences include a uniform CPU system versus a multistep SU system of certification. Furthermore, SU have obligatory elements of quality documentation but only facultative quality indicator assessment for CPUs. From an economic viewpoint operation and procedural key (OPS) numbers guarantee a better reflection of the use of resources in the complex treatment of stroke, which could not yet be established for CPUs.

CONCLUSION

The well-established CPU concept could additionally benefit from a superordinate quality control. Adequate quality benchmarking appears to be fundamental for gap analyses and for the establishment of a separate remuneration structure. In this respect the German Society for Cardiology as the certifying institution is required to establish an appropriate mechanism within the framework of regular updates of criteria.

[Certification : Pro: indispensable component of quality]

Certification is a critical component of quality assurance in medicine. From the certification of individual persons, through units and up to whole hospitals, certification stimulates testing and optimization of treatment processes, thereby improving the quality of care. Minimum case numbers needed to acquire a certificate are an important and objective attribute of quality. Advantages of certification include an improved treatment of patients, structured training of new employees and enhanced cost efficiency.

[Biomarkers in the diagnosis of cardiovascular emergencies : Acute coronary syndrome and differential diagnoses]

In emergency situations, patients present with symptoms rather than diagnoses. Due to its high prevalence, the acute coronary syndrome (ACS) dominates acute diagnostics as a consequence of its chief complaint chest pain. The challenge for the attending physicians is that only a minor part of patients with chest pain are finally diagnosed with an acute myocardial infarction (AMI) and that other rare but dangerous differential diagnoses have to be kept in mind and-vice versa-severely ill patients with AMI may present with symptoms other than chest pain. Against this background, the initial evaluation of patients requires a process-orientated view beyond the key roles of clinical assessment and biomarkers. The use of cardiac troponin is mandatory for the diagnosis of ACS, but challenging in broader utilization due to the reduced clinical specificity. Further relevant biomarkers are copeptin in combination with cardiac troponin or natriuetic peptides, which help to diagnose relevant cardiac dysfunction in (acute) heart failure. In addition, patients who present with the symptom of a suspected cardiac syncope need the differential diagnosis of an underlying arrhythmia, which may be due to an ACS or reduced left ventricular (LV) function and other causes like pulmonary embolism or structural heart disease (e. g. aortic valve stenosis). This highlights that biomarker-based diagnostics are often crucial to decide after the initial clinical evaluation whether early imaging is needed or early discharge is possible.

The German CPU registry: Comparison of smokers and nonsmokers

BACKGROUND

Chest pain is a major reason for admission to an internal emergency department, and smoking is a well-known risk factor for coronary artery disease (CAD) and acute coronary syndrome (ACS). The aim of this analysis is to illustrate the differences between smokers and nonsmokers presenting to German chest pain units (CPU) in regard to patient characteristics, CAD manifestation, treatment strategy, and prognosis.

METHODS

From December 2008 to March 2014, 13,902 patients who had a complete 3‑month follow-up were enrolled in the German CPU registry. The analysis comprised 5796 patients with ACS and documented smoking status.

RESULTS

Of all the patients in the CPU registry, 35.2% were smokers. Compared with nonsmokers, they were 13.5 years younger (58.2 vs. 71.7 years, p < 0.001), predominantly men (77.1% vs. 65.2%, p < 0.001), and were more frequently diagnosed with single-vessel disease (32.1% vs. 25.2%) as well as ST-elevation myocardial infarction (STEMI; 23.8% vs. 15.5%, p < 0.001). Although the Global Registry of Acute Coronary Events (GRACE) Risk Score for hospital mortality was lower in the group of smokers (106.1 vs. 123.3, p < 0.001), we did not observe any differences in CPU death (0.4% vs. 0.4%, p = 0.69) and CPU major adverse cardiac event (MACE) rates (3.8% vs 2.9%, p = 0.073) between the groups. In the 3‑month follow-up, we documented higher mortality rates in the nonsmoker group (1.9% vs. 2.9%, p = 0.035) in correlation with the GRACE Risk Score (80.3 vs. 105.2, p < 0.001). MACE rates were similar during the follow-up (3.1% vs. 4.1%, p = 0.065).

CONCLUSION

Observations from the German CPU registry demonstrate that smoking is a strong predictor of acute CAD manifestation early in life, especially STEMI. In spite of a lower GRACE Risk Score and fewer comorbidities, smokers had a rate of hospital mortality similar to the older group of nonsmokers.

[Emergency Medicine : What do we need?]

The timely medical treatment of the population in emergency situations is an enormous challenge for the healthcare system and is becoming increasingly more important. Due to this development clinical acute and emergency medicine has undergone enormous progress and is in the process of further professionalization. Various specialist societies and medical associations have published essential position papers in recent years and demanded fundamentally new healthcare structures and assignments. Additionally, emergency medical healthcare structures and centers have already been established on the initiative of individual emergency medical specialist disciplines. The future challenge is the nationwide establishment, grouping and integration of the structures and processes within definitive healthcare centers. The main objective of all involved must be the optimal care of emergency patients.

[Acute chest pain]

Patients presenting with acute chest pain are a challenge for attending physicians in private practice and specialists for emergency and acute medicine in hospitals because a wide spectrum of diagnoses may be the cause, ranging from acute myocardial infarction (AMI) to harmless muscular tension. The evaluation of patients with acute chest pain follows basic principles independent of the setting: A thorough clinical investigation by the responsible physician including medical history and physical examination, followed by a 12-channel electrocardiogram (ECG) and further focused diagnostics. The decision about hospital admission, monitoring and further diagnostic steps depends on the estimation of vital risk, the tentative diagnosis and the available diagnostic tools. Besides the ECG, laboratory tests (cardiac troponin, copeptin) and cardiac imaging (primarily the echocardiography) play a key role. Patients who did not necessarily require hospital admission (e. g. after exclusion of AMI) should be offered an inpatient or outpatient concept which enables the timely diagnosis and potential treatment of all relevant diseases in question. The diagnostic strategies need to take into account the pretest probability and for patients with confirmed diagnosis of an acute coronary syndrome (ACS), continuous monitoring and transfer to an emergency department with integrated chest pain unit (CPU) is strongly recommended. In this context, close collaboration between the emergency department and the physicians in private practice should be established.