1
|
Imhof S, Hochadel M, Konstantinides S, Voigtländer T, Schmitt C, Nowak B, Rassaf T, Senges J, Münzel T, Giannitsis E, Breuckmann F. Cardiac, possible cardiac, and likely non-cardiac origin of chest pain : A hitherto underestimated parameter in German chest pain units. Herz 2024; 49:175-180. [PMID: 38155226 DOI: 10.1007/s00059-023-05230-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Current guidelines emphasize the diagnostic value of non-cardiac or possibly cardiac chest pain. The goal of this analysis was to determine whether German chest pain units (CPUs) adequately address conditions with "atypical" chest pain in existing diagnostic structures. METHOD A total of 11,734 patients from the German CPU registry were included. The analyses included mode of admission, critical time intervals, diagnostic steps, and differential diagnoses. RESULTS Patients with unspecified chest pain were younger, more often female, were less likely to have classic cardiovascular risk factors and tended to present more often as self-referrals. Patients with acute coronary syndrome (ACS) mostly had prehospital medical contact. Overall, there was no difference between these two groups regarding the time from the onset of first symptoms to arrival at the CPU. In the CPU, the usual basic diagnostic measures were performed irrespective of ACS as the primary working diagnosis. In the non-ACS group, further ischemia-specific diagnostics were rarely performed. Extra-cardiac differential diagnoses were not specified. CONCLUSION The establishment of broader awareness programs and opening CPUs for low-threshold evaluation of self-referring patients should be discussed. Regarding the rigid focus on the clarification of cardiac causes of chest pain, a stronger interdisciplinary approach should be promoted.
Collapse
Affiliation(s)
- Sebastian Imhof
- Department of Cardiology, Pneumology, Neurology and Intensive Care, Klinik Kitzinger Land, Kitzingen, Germany
| | - Matthias Hochadel
- Institute for Myocardial Infarction Research Foundation, Ludwigshafen, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | | | - Claus Schmitt
- Clinic for Cardiology and Angiology, Municipal Hospital Karlsruhe, Karlsruhe, Germany
| | - Bernd Nowak
- CCB, Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Jochen Senges
- Institute for Myocardial Infarction Research Foundation, Ludwigshafen, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Mainz, Germany
| | | | - Frank Breuckmann
- Department of Cardiology, Pneumology, Neurology and Intensive Care, Klinik Kitzinger Land, Kitzingen, Germany.
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany.
| |
Collapse
|
2
|
Baradi A, Dinh DT, Brennan A, Stub D, Somaratne J, Palmer S, Nehme Z, Andrew E, Smith K, Liew D, Reid CM, Lefkovits J, Wilson A. Prevalence and Predictors of Emergency Medical Service Use in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction. Heart Lung Circ 2024:S1443-9506(24)00129-X. [PMID: 38570261 DOI: 10.1016/j.hlc.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/08/2024] [Accepted: 02/15/2024] [Indexed: 04/05/2024]
Abstract
AIM We aim to describe prevalence of Emergency Medical Service (EMS) use, investigate factors predictive of EMS use, and determine if EMS use predicts treatment delay and mortality in our ST-elevation myocardial infarction (STEMI) cohort. METHOD We prospectively collected data on 5,602 patients presenting with STEMI for primary percutaneous coronary intervention (PCI) transported to PCI-capable hospitals in Victoria, Australia, from 2013-2018 who were entered into the Victorian Cardiac Outcomes Registry (VCOR). We linked this dataset to the Ambulance Victoria and National Death Index (NDI) datasets. We excluded late presentation, thrombolysed, and in-hospital STEMI, as well as patients presenting with cardiogenic shock and out-of-hospital cardiac arrest. RESULTS In total, 74% of patients undergoing primary PCI for STEMI used EMS. Older age, female gender, higher socioeconomic status, and a history of prior ischaemic heart disease were independent predictors of using EMS. EMS use was associated with shorter adjusted door-to-balloon (53 vs 72 minutes, p<0.001) and symptom-to-balloon (183 vs 212 minutes, p<0.001) times. Mode of transport was not predictive of 30-day or 12-month mortality. CONCLUSIONS EMS use in Victoria is relatively high compared with internationally reported data. EMS use reduces treatment delay. Predictors of EMS use in our cohort are consistent with those prevalent in prior literature. Understanding the patients who are less likely to use EMS might inform more targeted education campaigns in the future.
Collapse
Affiliation(s)
- Arul Baradi
- Cambridge Cardiovascular Epidemiology Unit, Cambridge University, Cambridgeshire, United Kingdom; Department of Medicine, University of Melbourne, St Vincent's Hospital, Melbourne, Vic, Australia.
| | - Diem T Dinh
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Angela Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Dion Stub
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Vic, Australia
| | - Jithendra Somaratne
- Department of Cardiology, Auckland City Hospital, Auckland, New Zealand; Faculty of Medicine, University of Auckland, Auckland, New Zealand
| | - Sonny Palmer
- Department of Medicine, University of Melbourne, St Vincent's Hospital, Melbourne, Vic, Australia; Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia
| | - Ziad Nehme
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Vic, Australia
| | - Emily Andrew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Vic, Australia
| | - Karen Smith
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Vic, Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of General Medicine, Alfred Hospital, Melbourne, Vic, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; School of Public Health, Curtin University, Perth, WA, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Andrew Wilson
- Department of Medicine, University of Melbourne, St Vincent's Hospital, Melbourne, Vic, Australia; Department of Cardiology, St Vincent's Hospital, Melbourne, Vic, Australia
| |
Collapse
|
3
|
Breuckmann F, Settelmeier S, Rassaf T, Hochadel M, Nowak B, Voigtländer T, Giannitsis E, Senges J, Münzel T. Unexpected high level of severe events even in low-risk profile chest pain unit patients. Herz 2021; 47:374-379. [PMID: 34463785 PMCID: PMC9355921 DOI: 10.1007/s00059-021-05064-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 04/25/2021] [Accepted: 07/20/2021] [Indexed: 11/29/2022]
Abstract
AIMS Early heart attack awareness programs are thought to increase efficacy of chest pain units (CPU) by providing live-saving information to the community. We hypothesized that self-referral might be a feasible alternative to activation of emergency medical services (EMS) in selected chest pain patients with a specific low-risk profile. METHODS AND RESULTS In this observational registry-based study, data from 4743 CPU patients were analyzed for differences between those with or without severe or fatal prehospital or in-unit events (out-of-hospital cardiac arrest and/or in-unit death, resuscitation or ventricular tachycardia). In order to identify a low-risk subset in which early self-referral might be recommended to reduce prehospital critical time intervals, the Global Registry of Acute Coronary Events (GRACE) score for in-hospital mortality and a specific low-risk CPU score developed from the data by multivariate regression analysis were applied and corresponding event rates were calculated. Male gender, cardiac symptoms other than chest pain, first onset of symptoms and a history of myocardial infarction, heart failure or cardioverter defibrillator implantation increased propensity for critical events. Event rates within the low-risk subsets varied from 0.5-2.8%. Those patients with preinfarction angina experienced fewer events. CONCLUSIONS When educating patients and the general population about angina pectoris symptoms and early admission, activation of EMS remains recommended. Even in patients without any CPU-specific risk factor, self-referral bears the risk of severe or fatal pre- or in-unit events of 0.6%. However, admission should not be delayed, and self-referral might be feasible in patients with previous symptoms of preinfarction angina.
Collapse
Affiliation(s)
- Frank Breuckmann
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany.
| | - Stephan Settelmeier
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Matthias Hochadel
- Institute for Myocardial Infarction Research Foundation, Ludwigshafen, Germany
| | - Bernd Nowak
- Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
| | | | | | - Jochen Senges
- Institute for Myocardial Infarction Research Foundation, Ludwigshafen, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Mainz, Germany
| |
Collapse
|
4
|
Holzinger F, Oslislo S, Resendiz Cantu R, Möckel M, Heintze C. Diverting less urgent utilizers of emergency medical services to primary care: is it feasible? Patient and morbidity characteristics from a cross-sectional multicenter study of self-referring respiratory emergency department consulters. BMC Res Notes 2021; 14:113. [PMID: 33761978 PMCID: PMC7992314 DOI: 10.1186/s13104-021-05517-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/05/2021] [Indexed: 02/01/2023] Open
Abstract
Objective Diversion of less urgent emergency medical services (EMS) callers to alternative primary care (PC) is much debated. Using data from the EMACROSS survey of respiratory ED patients, we aimed to characterize self-referred EMS patients, compare these with non-EMS patients, and assess scope and acceptability of a potential redirection to alternative PC. Results Of n = 292 self-referred patients, n = 99 were transported by EMS. Compared to non-EMS patients, these were older, triaged more urgently and arrived out-of-hours more frequently. The share of chronically and severely ill patients was greater. Out-of-hours ED visit, presence of a chronic pulmonary condition as well as a hospital diagnosis of respiratory failure were identified as determinants of EMS utilization in a logistic model, while consultation for access and quality motives as well as migrant status decreased the probability. EMS-transported lower urgency outpatients visiting during regular physicians’ hours were defined as potential PC cases and evaluated descriptively (n = 9). As a third was medically complex and potentially less suitable for PC, redirection potential could be estimated at only 6% of EMS cases. This would be reduced to 2% if considering patients’ judgment concerning the appropriate setting. Overall, the scope for PC diversion of respiratory EMS patients seems limited.
Collapse
Affiliation(s)
- Felix Holzinger
- Institute of General Practice, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
| | - Sarah Oslislo
- Institute of General Practice, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| | - Rebecca Resendiz Cantu
- Institute of General Practice, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.,Division of Emergency Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Mitte and Virchow, Berlin, Germany
| | - Martin Möckel
- Division of Emergency Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Mitte and Virchow, Berlin, Germany
| | - Christoph Heintze
- Institute of General Practice, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany
| |
Collapse
|
5
|
German chest pain unit registry: data review after the first decade of certification. Herz 2020; 46:24-32. [PMID: 32232516 DOI: 10.1007/s00059-020-04912-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 01/24/2020] [Accepted: 03/03/2020] [Indexed: 01/12/2023]
Abstract
In 2008, the German Cardiac Society (GCS) introduced a certification program for specialized chest pain units (CPUs). In order to benchmark the performance of the certified CPUs, a nationwide German CPU registry was established. Since then, data for more than 34,000 patients have been included. The concept of certified CPUs in Germany has been widely accepted and its success is underlined by its recent inclusion in national and international guidelines. As of December 2019, 286 CPUs have been successfully certified or recertified by the GCS. This review focuses on the data retrieved from the CPU registry during the first decade of certification. As demonstrated by 16 manuscripts stemming from the registry, certified German CPUs demonstrate high quality of care in acute coronary syndrome and beyond. It is also noted that the German CPU registry allowed for further analysis of the gap in guideline adherence. With the current update of the CPU certification criteria, central data collection as a best-practice criterion will be abandoned, and after some productive years the registry has temporarily been stopped.
Collapse
|
6
|
Breuckmann F, Hochadel M, Grau AJ, Giannitsis E, Münzel T, Senges J. Quality benchmarks for chest pain units and stroke units in Germany. Herz 2020; 46:89-93. [PMID: 31970463 DOI: 10.1007/s00059-019-04881-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 10/05/2019] [Accepted: 12/06/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Chest pain units (CPUs) and stroke units (SUs) provide specialized multidisciplinary in-hospital management for acute chest pain and ischemic stroke. We analyzed exemplary equivalent quality benchmarks in both concepts. MATERIAL AND METHODS Data from the German CPU registry (2012-2015; 45 certified CPUs, 5881 patients) were compared with data from the SU registry of Rhineland-Palatinate (2011-2015; 29 SUs; 40,380 patients). Parameters comprised demographics, symptoms, diagnosis, medication, critical time intervals, therapeutics, and in-unit outcome. RESULTS Non-ST-segment elevation myocardial infarction (47.4%) and ischemic stroke (63.0%) were the most frequent entities. An electrocardiogram was performed on average within 7 min in CPUs, cranial imaging within 49 min in SUs. The mean time interval from admission until coronary intervention or lysis was 42 min or 57 min, respectively. Rates of antiplatelet therapy (90.1% vs. 96.0%), brain imaging, and coronary angiography were high (99.3% vs. 81.1%) and the mortality was low (0.8% for CPUs vs. 3.6% for SUs). The length of stay was shorter in CPUs (1.5 days vs. 4.4 days). CONCLUSION As reimbursement for emergency medicine in Germany was recently rearranged, quality benchmarking has gained incremental importance. Mandatory joint quality measurement in both concepts ensuring gap analysis and process improvement is encouraged.
Collapse
Affiliation(s)
- Frank Breuckmann
- Department of Cardiology, Herz-Jesu-Krankenhaus Dernbach, Südring 8, 56428, Dernbach, Germany.
| | - Matthias Hochadel
- Institute for Myocardial Infarction Research Foundation Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Armin J Grau
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen am Rhein, Germany
| | - Evangelos Giannitsis
- Department of Internal Medicine III, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Münzel
- Cardiology I, Center for Cardiology, University Medical Center Mainz, Mainz, Germany
| | - Jochen Senges
- Institute for Myocardial Infarction Research Foundation Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
7
|
Chest Pain Unit Network in Germany: Its Effect on Patients With Acute Coronary Syndromes. J Am Coll Cardiol 2019; 69:2459-2460. [PMID: 28494983 DOI: 10.1016/j.jacc.2017.03.562] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
8
|
Sepehrvand N, Alemayehu W, Kaul P, Pelletier R, Bello AK, Welsh RC, Armstrong PW, Ezekowitz JA. Ambulance use, distance and outcomes in patients with suspected cardiovascular disease: a registry-based geographic information system study. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 9:45-58. [PMID: 29652166 DOI: 10.1177/2048872618769872] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite guideline recommendations, the majority of patients with symptoms suggestive of acute coronary syndrome do not use emergency medical services to reach the emergency department (ED). The aim of this study was to investigate the factors associated with EMS utilisation and subsequent patient outcomes. METHODS Using administrative data, all patients who presented to an ED in the metropolitan areas of Edmonton and Calgary in the years of 2007-2013 with main ED diagnosis of acute coronary syndrome, stable angina or chest pain were included. The travel distance was estimated using the geographic information system method to approximate the distance between the ED and patient home. The clinical endpoints were the 7-day and 30-day all-cause events (death, re-hospitalisation and repeat ED visit). RESULTS Of 50,881 patients, 30.5% presented by emergency medical services. Patients with older age, female sex, ED diagnosis of acute coronary syndrome, more comorbidities and lower household income were more likely to use emergency medical services to reach the hospital. Longer travel distance was associated with higher emergency medical services use (odds ratio 1.09, 95% confidence interval 1.09-1.10), but it was not a predictor of clinical events. After adjustment for covariates and inverse propensity score weighting, emergency medical services use was associated with a higher risk of 7-day and 30-day clinical events. CONCLUSION Several demographic and clinical features were associated with higher emergency medical services use including geographical variation. Although longer travel distance was shown to be linked to higher emergency medical services use, it was not an independent predictor of patient outcome. This has implications for the design of emergency medical services systems, triage and early diagnosis and treatment options.
Collapse
Affiliation(s)
- Nariman Sepehrvand
- Canadian VIGOUR Centre, University of Alberta, Canada.,Department of Medicine, University of Alberta, Canada
| | | | - Padma Kaul
- Canadian VIGOUR Centre, University of Alberta, Canada.,Department of Medicine, University of Alberta, Canada
| | - Rick Pelletier
- Department of Renewable Resources, University of Alberta, Canada
| | - Aminu K Bello
- Department of Medicine, University of Alberta, Canada
| | - Robert C Welsh
- Canadian VIGOUR Centre, University of Alberta, Canada.,Department of Medicine, University of Alberta, Canada.,Mazankowski Alberta Heart Institute, Canada
| | | | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Canada.,Department of Medicine, University of Alberta, Canada.,Mazankowski Alberta Heart Institute, Canada
| |
Collapse
|
9
|
Vafaie M, Hochadel M, Münzel T, Hailer B, Schumacher B, Heusch G, Voigtländer T, Mudra H, Haude M, Barth S, Schmitt C, Darius H, Maier LS, Katus HA, Senges J, Giannitsis E. Guideline-adherence regarding critical time intervals in the German Chest Pain Unit registry. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018. [PMID: 29543035 DOI: 10.1177/2048872618762639] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Since 2008, the German Cardiac Society certified 256 Chest Pain Units (CPUs). Little is known about adherence to recommended performance measures in patients with suspected acute coronary syndrome (ACS) presenting to CPUs. We investigated guideline-adherence regarding critical time intervals and selected performance measures in German Chest Pain Units. METHODS From 2008 to 2014, 23,804 consecutive patients with suspected ACS were prospectively enrolled in the Chest Pain Unit registry of the German Cardiac Society. RESULTS Median time from symptom onset to first medical contact was 2 h in patients with ST-elevation myocardial infarction (STEMI) and 4 h in patients with unstable angina and non-STEMI (NSTEMI). In patients with STEMI, median time from hospital admission to percutaneous coronary intervention (PCI) was 40 min and median time from first medical contact to PCI was 1 h 35 min. Primary PCI was performed in 94.7% of patients with STEMI, 70.0% of patients with NSTEMI and 37.4% of patients with unstable angina. PCI was performed during the first 24 h in 79.5% of patients with NSTEMI and the first 72 h in 89.0% of patients with unstable angina. Electrocardiograms were performed in 99.5% after a median of 6 min after admission and obtained within 10 min in 71%. Interestingly, 56.1% of patients were found to have non-ACS diagnoses, underlining the importance of access to additional diagnostic modalities including echocardiography, stress testing or computed tomography. CONCLUSIONS Guideline-adherence regarding critical time intervals and primary PCI rates is good in German Chest Pain Units. More than half of patients admitted with suspected ACS had non-ACS diagnoses. Improvements in pre-hospital time delays through public awareness programmes are warranted.
Collapse
Affiliation(s)
- Mehrshad Vafaie
- Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Germany
| | - Matthias Hochadel
- Institute for Myocardial Infarction Research Foundation Ludwigshafen, Klinikum Ludwigshafen, Germany
| | - Thomas Münzel
- Centre for Cardiology, Cardiology I, Johannes Gutenberg-University Mainz, Germany
| | - Birgit Hailer
- Department of Cardiology, Catholic Clinics Essen-Northwest, Germany
| | | | - Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Centre, University of Essen Medical School, Germany
| | | | - Harald Mudra
- Department of Cardiology, Pneumology and Internal Intensive Care Medicine, Klinikum Neuperlach, Städtisches Klinikum München GmbH, Germany
| | - Michael Haude
- Medical Clinic I, Städtische Kliniken Neuss, Lukaskrankenhaus GmbH, Germany
| | - Sebastian Barth
- Department of Cardiology, Heart Centre Bad Neustadt, Bad Neustadt an der Saale, Germany
| | - Claus Schmitt
- Clinic for Cardiology and Angiology, Municipal Hospital Karlsruhe, Germany
| | - Harald Darius
- Department of Cardiology, Angiology and Intensive Care Medicine, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Lars S Maier
- Department of Internal Medicine II, University Hospital Regensburg, Germany
| | - Hugo A Katus
- Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Germany
| | - Jochen Senges
- Institute for Myocardial Infarction Research Foundation Ludwigshafen, Klinikum Ludwigshafen, Germany
| | - Evangelos Giannitsis
- Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Germany
| |
Collapse
|
10
|
Breuckmann F, Rassaf T. Early heart attack care as a prehospital programme designed to supplement the established chest pain unit concept in Germany. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 9:93-94. [PMID: 29417828 DOI: 10.1177/2048872618759316] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, University Duisburg-Essen, Germany
| |
Collapse
|
11
|
Characterization and referral patterns of ST-elevation myocardial infarction patients admitted to chest pain units rather than directly to catherization laboratories. Data from the German Chest Pain Unit Registry. Int J Cardiol 2017; 231:31-35. [PMID: 28189192 DOI: 10.1016/j.ijcard.2016.12.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/29/2016] [Accepted: 12/05/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Direct transfer to the catheterization laboratory for primary percutaneous coronary intervention (PCI) is standard of care for patients with ST-segment elevation myocardial infarction (STEMI). Nevertheless, a significant number of STEMI-patients are initially treated in chest pain units (CPUs) of admitting hospitals. Thus, it is important to characterize these patients and to define why an important deviation from recommended clinical pathways occurs and in particular to quantify the impact of deviation on critical time intervals. METHODS AND RESULTS 1679 STEMI patients admitted to a CPU in the period from 2010 to 2015 were enrolled in the German CPU registry (8.5% of 19,666). 55.9% of the patients were delivered by an emergency medical system (EMS), 16.1% transferred from other hospitals and 15.2% referred by a general practitioner (GP). 12.7% were self-referrals. 55% did not get a pre-hospital ECG. Compared to the EMS, referral by GPs markedly delayed critical time intervals while a pre-hospital ECG demonstrating ST-segment elevation reduced door-to-balloon time. When compared to STEMI patients (n=21,674) enrolled in the ALKK-registry, CPU-STEMI patients had a lower risk profile, their treatment in the CPU was guideline-conform and in-hospital mortality was low (1.5%). CONCLUSIONS CPU-STEMI patients represent a numerically significant group because a pre-hospital ECG was not documented. Treatment in the CPU is guideline-conform and the intra-hospital mortality is low. The lack of a pre-hospital ECG and admission via the GP substantially delay critical time intervals suggesting that in patients with symptoms suggestive an ACS, the EMS should be contacted and not the GP.
Collapse
|
12
|
Roubille F, Mercier G, Delmas C, Manzo-Silberman S, Leurent G, Elbaz M, Riondel A, Bonnefoy-Cudraz E, Henry P. Description of acute cardiac care in 2014: A French nation-wide database on 277,845 admissions in 270 ICCUs. Int J Cardiol 2017; 240:433-437. [PMID: 28400122 DOI: 10.1016/j.ijcard.2017.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/10/2017] [Accepted: 04/03/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Intensive Cardiac Care Unit (ICCU) has greatly evolved for decades: it no longer includes only patients with coronary artery disease (CAD). The clinical characteristics and pathological profiles of patients have markedly changed. Detailed data on the topic are critically lacking. METHODS We present here a French nation-wide administrative database with an exhaustive description of patients admitted to ICCU throughout a whole year (2014). RESULTS A total of 277,845 patients in 270 centers were admitted to ICCUs at least once in 2014 (exhaustive data). Median age was 71years (IQR: 59-81) and the patients were primarily male (63%). Mean ICCU stay was 2.0days (1.0-4.0). CAD patients (49.0%) represented the major group admitted, followed by patients with arrhythmias (15.2%) and heart failure (HF) (10.0%). Patients admitted with acute CAD were significantly younger (mean age 67.4 y), had better outcomes (mortality 4.0%), and shorter hospital stays (mean stay 6.7 d). Patients with HF were significantly older (mean age 75.2 y), with longer hospital stays (mean stay 12.0 d), and poorer outcomes (mortality 10.5%). CONCLUSION We present here the largest contemporary administrative database on patients admitted to ICCUs in a developed country. CAD (mainly acute coronary syndromes) remains the primary cause of admission but the population is, by far, more complex than generally considered.
Collapse
Affiliation(s)
- François Roubille
- Cardiology Department, University Hospital of Montpellier, Montpellier, France; PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, 34295 Montpellier cedex 5, France.
| | - Grégoire Mercier
- Economic Evaluation Unit at Montpellier Teaching Hospital, University of Montpellier, Montpellier, France
| | - Clément Delmas
- Intensive Cardiac Care Unit, Cardiology Department, University Hospital of Rangueil, Toulouse, France
| | - Stéphane Manzo-Silberman
- Department of Cardiology, Inserm U942, Lariboisière Hospital, AP-HP, Paris Diderot University, Paris, France
| | - Guillaume Leurent
- CHU Rennes, Service de Cardiologie et Maladies Vasculaires, Rennes F-35000, France
| | - Meyer Elbaz
- Intensive Cardiac Care Unit, Cardiology Department, University Hospital of Rangueil, Toulouse, France
| | - Adeline Riondel
- Economic Evaluation Unit at Montpellier Teaching Hospital, University of Montpellier, Montpellier, France
| | | | - Patrick Henry
- Department of Cardiology, Inserm U942, Lariboisière Hospital, AP-HP, Paris Diderot University, Paris, France
| |
Collapse
|
13
|
Varnavas V, Rassaf T, Breuckmann F. Nationwide but still inhomogeneous distribution of certified chest pain units across Germany : Need to strengthen rural regions. Herz 2017; 43:78-86. [PMID: 28116466 DOI: 10.1007/s00059-016-4527-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 12/14/2016] [Indexed: 11/24/2022]
Abstract
AIM The purpose of this work was to analyze structure, distribution, and bed capacities of certified German chest pain units (CPUs) to unveil potential gaps despite nationwide certification of 230 units till the end of 2015. METHODS Analysis of number and structure of CPUs per state, resident count, and population density by standardized telephone interview, online research, and data collection from the registry of the Federal Statistical Office for all certified German CPUs. RESULTS Nationwide, German health facilities provided a mean of 1 CPU bed within a certified unit per 65,000 inhabitants. Bremen, Hamburg, Hesse, and Rhineland-Palatinate provided more than 1 bed per 50,000 inhabitants. Most CPUs (49%) were located in the emergency room. All university hospitals in Germany provided a certified CPU. Most units were found in academic teaching hospitals (146 CPUs). Only 42 CPUs were found in nonacademic providers of primary health care. CONCLUSION The absolute necessary number of CPUs to reach full nationwide coverage is still unknown. The current analysis shows a high number of CPUs and bed capacities within the cities and industrial areas without relevant gaps, but also demonstrates a certain undersupply in more rural areas as well as in some of the former eastern federal states of Germany.
Collapse
Affiliation(s)
- V Varnavas
- West German Heart and Vascular Center Essen, Department of Cardiology and Vascular Medicine, University Duisburg-Essen, Essen, Germany
| | - T Rassaf
- West German Heart and Vascular Center Essen, Department of Cardiology and Vascular Medicine, University Duisburg-Essen, Essen, Germany
| | - F Breuckmann
- Department of Cardiology, Arnsberg Medical Center, Stolte Ley 5, 59759, Arnsberg, Germany.
| |
Collapse
|
14
|
First Update of the Criteria for Certification of Chest Pain Units in Germany: Facelift or New Model? Crit Pathw Cardiol 2016; 15:29-31. [PMID: 26881818 DOI: 10.1097/hpc.0000000000000064] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE In an effort to provide a systematic and specific standard-of-care for patients with acute chest pain, the German Cardiac Society introduced criteria for certification of specialized chest pain units (CPUs) in 2008, which have been replaced by a recent update published in 2015. METHODS We reviewed the development of CPU establishment in Germany during the past 7 years and compared and commented the current update of the certification criteria. RESULTS As of October 2015, 228 CPUs in Germany have been successfully certified by the German Cardiac Society; 300 CPUs are needed for full coverage closing gaps in rural regions. Current changes of the criteria mainly affect guideline-adherent adaptions of diagnostic work-ups, therapeutic strategies, risk stratification, in-hospital timing and education, and quality measures, whereas the overall structure remained unchanged. Benchmarking by participation within the German CPU registry is encouraged. CONCLUSION Even though the history is short, the concept of certified CPUs in Germany is accepted and successful underlined by its recent implementation in national and international guidelines. First registry data demonstrated a high standard of quality-of-care. The current update provides rational adaptions to new guidelines and developments without raising the level for successful certifications. A periodic release of fast-track updates with shorter time frames and an increase of minimum requirements should be considered.
Collapse
|
15
|
Breuckmann F, Hochadel M, Voigtländer T, Haude M, Schmitt C, Münzel T, Giannitsis E, Mudra H, Heusch G, Schumacher B, Barth S, Schuler G, Hailer B, Walther D, Senges J. The Use of Echocardiography in Certified Chest Pain Units: Results from the German Chest Pain Unit Registry. Cardiology 2016; 134:75-83. [PMID: 26910053 DOI: 10.1159/000443475] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 12/16/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To analyze the current usage of transthoracic echocardiography (TTE) as a rapid, noninvasive tool in the early stratification of acute chest pain in certified German chest pain units (CPUs). METHODS A total of 23,997 patients were enrolled. Analyses comprised TTE evaluation rates in relation to clinical presentation, risk profile, left ventricular impairment, final diagnosis and invasive management. Critical times were assessed. Multivariable analyses for independent determinants for the use of TTE were performed. RESULTS TTE evaluation was available in CPUs in 70.1% of cases. It was associated with lower rates of invasive management in unstable angina pectoris (UAP) and with higher rates in patients with initially suspected non-cardiac origin of symptoms and/or reduced systolic function (p < 0.05). Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) was an independent determinant favoring TTE evaluation [NSTE-myocardial infarction: odds ratio (OR) 1.62; UAP: OR 1.34; p < 0.001 for both]. Clinical signs of heart failure (OR 1.31; p < 0.001), referral by emergency medical service (OR 1.18; p < 0.001) and kidney failure (OR 1.16; p < 0.05) were independently associated with higher TTE rates. TTE did not delay door-to-balloon times. CONCLUSIONS About two thirds of the patients admitted to certified CPUs received TTE evaluation, with the highest rates being in ACS patients, and thereby providing diagnostic information supporting or refuting further invasive management.
Collapse
Affiliation(s)
- Frank Breuckmann
- Department of Cardiology, Arnsberg Medical Center, Arnsberg, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Guideline-conforming timing of invasive management in troponin-positive or high-risk ACS without persistent ST-segment elevation in German chest pain units. Urban university maximum care vs. rural regional primary care. Herz 2015; 41:151-8. [PMID: 26407695 DOI: 10.1007/s00059-015-4354-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 07/03/2015] [Accepted: 08/18/2015] [Indexed: 12/22/2022]
Abstract
AIM This study aimed to analyze guideline adherence in the timing of invasive management for myocardial infarction without persistent ST-segment elevation (NSTEMI) in two exemplary German centers, comparing an urban university maximum care facility and a rural regional primary care facility. METHODS All patients diagnosed as having NSTEMI during 2013 were retrospectively enrolled in two centers: (1) site I, a maximum care center in an urban university setting, and (b) site II, a primary care center in a rural regional care setting. Data acquisition included time intervals from admission to invasive management, risk criteria, rate of intervention, and medical therapy. RESULTS The median time from admission to coronary angiography was 12.0 h (site I) or 17.5 h (site II; p = 0.17). Guideline-adherent timing was achieved in 88.1 % (site I) or 82.9 % (site II; p = 0.18) of cases. Intervention rates were high in both sites (site I-75.5 % vs. site II-75.3 %; p = 0.85). Adherence to recommendations of medical therapy was high and comparable between the two sites. CONCLUSION In NSTEMI or high-risk acute coronary syndromes without persistent ST-segment elevation, guideline-adherent timing of invasive management was achieved in about 85 % of cases, and was comparable between urban maximum and rural primary care settings. Validation by the German Chest Pain Unit Registry including outcome analysis is required.
Collapse
|
17
|
Post F, Gori T, Giannitsis E, Darius H, Baldus S, Hamm C, Hambrecht R, Hofmeister HM, Katus H, Perings S, Senges J, Münzel T. Criteria of the German Society of Cardiology for the establishment of chest pain units: update 2014. Clin Res Cardiol 2015; 104:918-28. [PMID: 26150114 PMCID: PMC4623090 DOI: 10.1007/s00392-015-0888-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 06/23/2015] [Indexed: 12/22/2022]
Abstract
Since 2008, the German Cardiac Society (DGK) has been establishing a network of certified chest pain units (CPUs). The goal of CPUs was and is to carry out differential diagnostics of acute or newly occurring chest pain of undetermined origin in a rapid and goal-oriented manner and to take immediate therapeutic measures. The basis for the previous certification process was criteria that have been established and published by the task force on CPUs. These criteria regulate the spatial and technical requirements and determine diagnostic and therapeutic strategies in patients with chest pain. Furthermore, the requirements for the organization of CPUs and the training requirements for the staff of a CPU are defined. The certification process is carried out by the DGK; currently, 225 CPUs are certified and 139 CPUs have been recertified after running for a period of 3 years. The certification criteria have now been revised and updated according to new guidelines.
Collapse
Affiliation(s)
- Felix Post
- Katholisches Klinikum Koblenz Montabaur, Koblenz, Germany
| | - Tommaso Gori
- II. Medizinische Klinik und Poliklinik für Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | | | - Harald Darius
- Department für Kardiologie, Innere Medizin und Intensivmedizin, Vivantes-Klinikum Neukölln, Berlin, Germany
| | - Stephan Baldus
- Klinikum III für Innere Medizin Uniklinik Köln, Cologne, Germany
| | | | - Rainer Hambrecht
- Klinik für Kardiologie und Angiologie, Herzzentrum Bremen, Bremen, Germany
| | | | - Hugo Katus
- Klinik für KardiologieAngiologie und Pneumonologie, Heidelberg, Germany
| | | | - Jochen Senges
- Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Thomas Münzel
- II. Medizinische Klinik und Poliklinik für Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Germany.
| |
Collapse
|
18
|
Breuckmann F, Burt DR, Melching K, Erbel R, Heusch G, Senges J, Garvey JL. Chest Pain Centers: A Comparison of Accreditation Programs in Germany and the United States. Crit Pathw Cardiol 2015; 14:67-73. [PMID: 26102016 DOI: 10.1097/hpc.0000000000000041] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE The implementation of chest pain centers (CPC)/units (CPU) has been shown to improve emergency care in patients with suspected cardiac ischemia. METHODS In an effort to provide a systematic and specific standard of care for patients with acute chest pain, the Society of Cardiovascular Patient Care (SCPC) as well as the German Cardiac Society (GCS) introduced criteria for the accreditation of specialized units. RESULTS To date, 825 CPCs in the United States and 194 CPUs in Germany have been successfully certified by the SCPC or GCS, respectively. Even though there are differences in the accreditation processes, the goals are quite similar, focusing on enhanced operational efficiencies in the care of the acute coronary syndrome patients, reduced time delays, improved diagnostic and therapeutic strategies using adapted standard operating procedures, and increased medical as well as community awareness by the implementation of nationwide standardized concepts. In addition to national efforts, both societies have launched international initiatives, accrediting CPCs/CPU in the Middle East and China (SCPC) and Switzerland (GCS). CONCLUSION Enhanced collaboration among international bodies interested in promoting high quality care might extend the opportunity for accreditation of facilities that treat cardiovascular patients, with national programs designed to meet local needs and local healthcare system requirements.
Collapse
Affiliation(s)
- Frank Breuckmann
- From the *Department of Cardiology, Arnsberg Medical Center, Arnsberg, Germany; †Department of Emergency Medicine, University of Virginia, Charlottesville, VA; ‡Society of Cardiovascular Patient Care, Dublin, OH; §Department of Cardiology, West German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany; ¶Institute for Pathophysiology, West German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany; ‖Institute for Myocardial Infarction Research Foundation Ludwigshafen, University of Heidelberg, Heidelberg, Germany; and **Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC
| | | | | | | | | | | | | |
Collapse
|
19
|
Kriterien der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung für „Chest Pain Units“. KARDIOLOGE 2015. [DOI: 10.1007/s12181-014-0646-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
|
20
|
The German CPU Registry: Dyspnea independently predicts negative short-term outcome in patients admitted to German Chest Pain Units. Int J Cardiol 2015; 181:88-95. [DOI: 10.1016/j.ijcard.2014.11.199] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 10/28/2014] [Accepted: 11/24/2014] [Indexed: 01/21/2023]
|