Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule

Development and implementation of a treatment pathway to reduce coronary angiograms - lessons from a failure

BACKGROUND

The rates of coronary angiograms (CA) and related procedures (percutaneous intervention [PCI]) are significantly higher in Germany than in other Organisation for Economic Co-ordination and Development (OECD) countries. The current guidelines recommend non-invasive diagnosis of coronary heart disease (CHD); CA should only have a limited role in choosing the appropriate revascularisation procedure. The aim of the present study was to explore whether improvements in guideline adherence can be achieved through the implementation of regional treatment pathways. We chose four regions of Germany with high utilisation of CAs for the study. Here we report the results of the concomitant qualitative study.

METHODS

General practitioners and specialist physicians (cardiologists, hospital-based cardiologists, emergency physicians, radiologists and nuclear medicine specialists) caring for patients with suspected CHD were invited to develop regional treatment pathways. Four academic departments provided support for moderation, provision of materials, etc. The study team observed session discussions and took notes. After the development of the treatment pathways, 45 semi-structured interviews were conducted with the participating physicians. Interviews and field notes were transcribed verbatim and underwent qualitative content analysis.

RESULTS

Pathway development received little support among the participants. Although consensus documents were produced, the results were unlikely to improve practice. The participants expressed very little commitment to change. Although this attempt clearly failed in all study regions, our experience provides relevant insights into the process of evidence appraisal and implementation. A lack of organisational skills, ignorance of current evidence and guidelines, and a lack of feedback regarding one's own clinical behaviour proved to be insurmountable. CA was still seen as the diagnostic gold standard by most interviewees.

CONCLUSIONS

Oversupply and overutilisation can be assumed to be present in study regions but are not immediately perceived by clinicians. The problem is unlikely to be solved by regional collaborative initiatives; optimised resource planning within the health care system combined with appropriate economic incentives might best address these issues.

The LEADING Guideline. Reporting Standards for Expert Panel, Best-Estimate Diagnosis, and Longitudinal Expert All Data (LEAD) Studies

Accurate assessments of symptoms and diagnoses are essential for health research and clinical practice but face many challenges. The absence of a single error-free measure is currently addressed by assessment methods involving experts reviewing several sources of information to achieve a more accurate or best-estimate assessment. Three bodies of work spanning medicine, psychiatry, and psychology propose similar assessment methods: The Expert Panel, the Best-Estimate Diagnosis, and the Longitudinal Expert All Data (LEAD). However, the quality of such best-estimate assessments is typically very difficult to evaluate due to poor reporting of the assessment methods and when it is reported, the reporting quality varies substantially. Here we tackle this gap by developing reporting guidelines for such studies, using a four-stage approach: 1) drafting reporting standards accompanied by rationales and empirical evidence, which were further developed with a patient organization for depression, 2) incorporating expert feedback through a two-round Delphi procedure, 3) refining the guideline based on an expert consensus meeting, and 4) testing the guideline by i) having two researchers test it and ii) using it to examine the extent previously published articles report the standards. The last step also demonstrates the need for the guideline: 18 to 58% (Mean = 33%) of the standards were not reported across fifteen randomly selected studies. The LEADING guideline comprises 20 reporting standards related to four groups: The Longitudinal design ; the Appropriate data ; the Evaluation - experts, materials, and procedures ; and the Validity group. We hope that the LEADING guideline will be useful in assisting researchers in planning, reporting, and evaluating research aiming to achieve best-estimate assessments. Open data (Delphi surveys 1 and 2), code (analyses), and material (surveys): https://osf.io/fkv4b/.

Acute Coronary Syndrome

One percent of primary care visits are due to chest pain. It is critical for the primary care physician to have a high index of suspicion for acute coronary syndrome and understand the management of this important condition. This article reviews the outpatient evaluation and management of chest pain and summarizes the key points of inpatient evaluation and treatment of acute coronary syndrome.

AI Algorithm to Predict Acute Coronary Syndrome in Prehospital Cardiac Care: Retrospective Cohort Study

BACKGROUND

Overcrowding of hospitals and emergency departments (EDs) is a growing problem. However, not all ED consultations are necessary. For example, 80% of patients in the ED with chest pain do not have an acute coronary syndrome (ACS). Artificial intelligence (AI) is useful in analyzing (medical) data, and might aid health care workers in prehospital clinical decision-making before patients are presented to the hospital.

OBJECTIVE

The aim of this study was to develop an AI model which would be able to predict ACS before patients visit the ED. The model retrospectively analyzed prehospital data acquired by emergency medical services' nurse paramedics.

METHODS

Patients presenting to the emergency medical services with symptoms suggestive of ACS between September 2018 and September 2020 were included. An AI model using a supervised text classification algorithm was developed to analyze data. Data were analyzed for all 7458 patients (mean 68, SD 15 years, 54% men). Specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for control and intervention groups. At first, a machine learning (ML) algorithm (or model) was chosen; afterward, the features needed were selected and then the model was tested and improved using iterative evaluation and in a further step through hyperparameter tuning. Finally, a method was selected to explain the final AI model.

RESULTS

The AI model had a specificity of 11% and a sensitivity of 99.5% whereas usual care had a specificity of 1% and a sensitivity of 99.5%. The PPV of the AI model was 15% and the NPV was 99%. The PPV of usual care was 13% and the NPV was 94%.

CONCLUSIONS

The AI model was able to predict ACS based on retrospective data from the prehospital setting. It led to an increase in specificity (from 1% to 11%) and NPV (from 94% to 99%) when compared to usual care, with a similar sensitivity. Due to the retrospective nature of this study and the singular focus on ACS it should be seen as a proof-of-concept. Other (possibly life-threatening) diagnoses were not analyzed. Future prospective validation is necessary before implementation.

Ruling out acute coronary syndrome in primary care with a clinical decision rule and a capillary, high-sensitive troponin I point of care test: study protocol of a diagnostic RCT in the Netherlands (POB HELP)

INTRODUCTION

Chest pain is a common reason for consultation in primary care. To rule out acute coronary syndrome (ACS), general practitioners (GP) refer 40%-70% of patients with chest pain to the emergency department (ED). Only 10%-20% of those referred, are diagnosed with ACS. A clinical decision rule, including a high-sensitive cardiac troponin-I point-of-care test (hs-cTnI-POCT), may safely rule out ACS in primary care. Being able to safely rule out ACS at the GP level reduces referrals and thereby alleviates the burden on the ED. Moreover, prompt feedback to the patients may reduce anxiety and stress.

METHODS AND ANALYSIS

The POB HELP study is a clustered randomised controlled diagnostic trial investigating the (cost-)effectiveness and diagnostic accuracy of a primary care decision rule for acute chest pain, consisting of the Marburg Heart Score combined with a hs-cTnI-POCT (limit of detection 1.6 ng/L, 99th percentile 23 ng/L, cut-off value between negative and positive used in this study 3.8 ng/L). General practices are 2:1 randomised to the intervention group (clinical decision rule) or control group (regular care). In total 1500 patients with acute chest pain are planned to be included by GPs in three regions in The Netherlands. Primary endpoints are the number of hospital referrals and the diagnostic accuracy of the decision rule 24 hours, 6 weeks and 6 months after inclusion.

ETHICS AND DISSEMINATION

The medical ethics committee Leiden-Den Haag-Delft (the Netherlands) has approved this trial. Written informed consent will be obtained from all participating patients. The results of this trial will be disseminated in one main paper and additional papers on secondary endpoints and subgroup analyses.

TRIAL REGISTRATION NUMBERS

NL9525 and NCT05827237.

Determinants of referral for suspected coronary artery disease: a qualitative study based on decision thresholds

BACKGROUND

Chest pain is a frequent consultation issue in primary care, with coronary artery disease (CAD) being a serious potential cause. Primary care physicians (PCPs) assess the probability for CAD and refer patients to secondary care if necessary. Our aim was to explore PCPs' referral decisions, and to investigate determinants which influenced those decisions.

METHODS

PCPs working in Hesse, Germany, were interviewed in a qualitative study. We used 'stimulated recall' with participants to discuss patients with suspected CAD. With a sample size of 26 cases from nine practices we reached inductive thematic saturation. Interviews were audio-recorded, transcribed verbatim and analyzed by inductive-deductive thematic content analysis. For the final interpretation of the material, we used the concept of decision thresholds proposed by Pauker and Kassirer.

RESULTS

PCPs reflected on their decisions for or against a referral. Aside from patient characteristics determining disease probability, we identified general factors which can be understood as influencing the referral threshold. These factors relate to the practice environment, to PCPs themselves and to non-diagnostic patient characteristics. Proximity of specialist practice, relationship with specialist colleagues, and trust played a role. PCPs sometimes felt that invasive procedures were performed too easily. They tried to steer their patients through the system with the intent to avoid over-treatment. Most PCPs were unaware of guidelines but relied on informal local consensus, largely influenced by specialists. As a result, PCPs gatekeeping role was limited.

CONCLUSIONS

We could identify a large number of factors that impact referral for suspected CAD. Several of these factors offer possibilities to improve care at the clinical and system level. The threshold model proposed by Pauker and Kassirer was a useful framework for this kind of data analysis.

Evaluation of the Marburg Heart Score and INTERCHEST score compared to current telephone triage for chest pain in out-of-hours primary care

INTRODUCTION

Chest pain is a common and challenging symptom for telephone triage in urgent primary care. Existing chest-pain-specific risk scores originally developed for diagnostic purposes may outperform current telephone triage protocols.

METHODS

This study involved a retrospective, observational cohort of consecutive patients evaluated for chest pain at a large-scale out-of-hours primary care facility in the Netherlands. We evaluated the performance of the Marburg Heart Score (MHS) and INTERCHEST score as stand-alone triage tools and compared them with the current decision support tool, the Netherlands Triage Standard (NTS). The outcomes of interest were: C‑statistics, calibration and diagnostic accuracy for optimised thresholds with major events as the reference standard. Major events are a composite of all-cause mortality and both cardiovascular and non-cardiovascular urgent underlying conditions occurring within 6 weeks of initial contact.

RESULTS

We included 1433 patients, 57.6% women, with a median age of 55.0 years. Major events occurred in 16.4% (n = 235), of which acute coronary syndrome accounted for 6.8% (n = 98). For predicting major events, C‑statistics for the MHS and INTERCHEST score were 0.74 (95% confidence interval: 0.70-0.77) and 0.76 (0.73-0.80), respectively. In comparison, the NTS had a C-statistic of 0.66 (0.62-0.69). All had appropriate calibration. Both scores (at threshold ≥ 2) reduced the number of referrals (with lower false-positive rates) and maintained equal safety compared with the NTS.

CONCLUSION

Diagnostic risk stratification scores for chest pain may also improve telephone triage for major events in out-of-hours primary care, by reducing the number of unnecessary referrals without compromising triage safety. Further validation is warranted.

Simplified Geleijnse score for identifying chest pain features associated with coronary ischemia

BACKGROUND

The Geleijnse score, which was proposed to assess for coronary ischemia, has practical limitations.

OBJECTIVES

Our aim was to design and evaluate a simplified version of the Geleijnse score.

METHODS

We enrolled patients with suspected coronary heart disease but negative troponin T or absence of enzymatic curve, and a non-diagnostic 12-lead ECG. The initial study was performed in a retrospective derivation cohort and the results were subsequently validated in a prospective cohort.

RESULTS

From 109 patients included in the derivation cohort, 33 (30.3%) received a diagnosis of coronary heart disease. Chest pain with both arms radiation (OR 3.54), severe intensity (OR 2.41), improvement by nitroglycerin (OR 1.61), associated dyspnea (OR 1.97) and prior exertional angina history (OR 2.91) were independently associated with an ischemic origin on multivariate logistic regression analysis. ROC curves comparison demonstrated both the original and simplified scores presented modest predictive ability with significant difference when analyzed using dichotomous cut-offs (0.647 [simplified] vs. 0.544 [original], p = 0.042) but not as a continuous variable (0.670 [simplified] vs. 0.621 [original], p = 0.396). In 305 patients from the validation cohort, the simplified score presented extensively increased predictive accuracy than the Geleijnse, in the continuous (c-indexes = 0.735 vs. 0.685, p = 0.040) and the dichotomic (c-indexes = 0.682 vs. 0.514, p<0.001) forms.

CONCLUSIONS

A simplified version of the Geleijnse score, including some routine clinical manifestations associated with coronary heart disease, presented significantly better predictive ability compared to the original score.

Predictors of critical illness among young males with chest pain, abdominal pain, or headaches in the Republic of Korea Army

Purpose

Chest pain, abdominal pain, and headache are common symptoms associated with critical illness. Here, we aimed to evaluate predictors associated with critical illness in young males of the Republic of Korea Army.

Methods

We retrospectively reviewed previously healthy young males with chest pain, abdominal pain, or headaches who visited Armed Forces Seoul District Hospital between January 2019 and December 2020. Critical illness was defined as a condition that required hospitalization, a procedure or surgery, or referral to a tertiary hospital. The symptoms and signs of critical illness were evaluated.

Results

Of the 762 enrolled patients, a critical illness was diagnosed in 45 patients (5.9%). Among chest pain signs, palpitation (odds ratio [OR], 22.8; 95% confidence interval [CI], 5.08-102.4; p < 0.001), exertional dyspnea (OR, 16.3; 95% CI, 3.38-78.8; p = 0.001), duration (> 5 minutes) (OR, 7.54; 95% CI, 1.93-29.49; p = 0.004), and squeezing type (OR, 5.28; 95% CI, 1.11-25.11; p = 0.037) were significantly associated with critical illness. Among abdominal pain signs, right-lower-quadrant tenderness (OR, 11.87; 95% CI, 4.671-31.87; p < 0.001) was an alarming sign. For headaches, criticality was low (1.5%), and half of patients with critical illness were diagnosed incidentally regardless of headache.

Conclusion

We identified symptoms and signs significantly associated with critical illness in young male patients. This study might serve as a reference for deciding when to transfer soldiers in the field to a rear hospital, thereby contributing to the welfare and combat power of soldiers.

What they don't teach you in medical school: helping the patient with chest pain of unknown cause

Chest pain is a common presenting complaint with a broad differential diagnosis. Even after the full array of special investigations, a cause cannot be found in some patients. Psychological factors can play a significant role in the perception of chest pain. Patients with such a psychological disturbance may not meet the full criteria for a diagnosable psychiatric illness, and thus cannot be assigned a specific diagnosis. Not knowing how to manage this situation can lead to poor rapport between doctor and patient. Through their clinical acumen, judicious use of special investigations and by forming a therapeutic alliance, clinicians can identify and help these patients.

Performance of risk scores for coronary artery disease: a retrospective cohort study of patients with chest pain in urgent primary care

OBJECTIVE

To evaluate the diagnostic performance of the Marburg Heart Score (MHS), INTERCHEST, Gencer rule, Bruins Slot rule and compare these with unaided clinical judgement in patients with chest pain in urgent primary care.

DESIGN

Retrospective, cohort study.

SETTING

Regional primary care facility responsible for out-of-hours primary care for a quarter-million people in the Netherlands.

PARTICIPANTS

Consecutive patients aged ≥18 years who were evaluated for chest pain.

MAIN OUTCOME MEASURES

Discriminatory ability (C-statistic), sensitivity, specificity, positive and negative predictive values (PPV/NPV). The reference standard involved a composite endpoint of the occurrence of death, acute coronary syndrome or coronary revascularisation (=major adverse cardiac events; MACE) up to 6 weeks after initial contact.

RESULTS

A total of 664 patients were included, of whom 4.8% (n=32) had a MACE event. C-statistics for MHS, INTERCHEST, Gencer and Bruins Slot rule were: 0.77 (95% CI 0.69 to 0.84), 0.85 (95% CI 0.78 to 0.92), 0.72 (95% CI 0.63 to 0.81) and 0.72 (95% CI 0.63 to 0.81), respectively. Optimal diagnostic accuracy was found for MHS ≥2 (sensitivity=81.3%, specificity=67.1%, PPV=11.1%, NPV=98.6%), INTERCHEST ≥2 (sensitivity=87.5%, specificity=78.8%, PPV=17.3%, NPV=99.1%), Gencer ≥2 (sensitivity=84.4%, specificity=37.8%, PPV=6.4%, NPV=98.0%) and Bruins Slot≥2 (sensitivity=90.6%, specificity=40.8%, PPV=7.2%, NPV=98.9%). Physicians referred 157 patients (23.6%) and missed 6 out of 32 MACEs (sensitivity=81.3%, specificity=79.3%, PPV=16.6%, NPV=98.8%). Using INTERCHEST with a referral threshold of ≥2 points, 4 MACEs would have been missed and 162 patients (24.4%) referred. The other risk scores resulted in far higher referral rates.

CONCLUSION

While available risk scores have reasonable to good discriminatory properties, they do not outperform unaided clinical judgment for evaluating chest pain in urgent primary care. Only the INTERCHEST score may slightly improve risk stratification.

Telephone triage of young adults with chest pain: population analysis of NHS24 calls in Scottish unscheduled care

BACKGROUND

Telephone triage is increasingly used to manage unscheduled care demand. Younger adults are frequent users, and commonly call with chest pain. We compared pathways of care in younger adults calling with chest pain, and associations of patient characteristics and telephone triage recommendation with hospital admission.

METHODS

A retrospective study of all triage calls with chest pain to NHS24 advice line by people aged 15-34 years between 1 January 2015 and 31 December 2017 where chest pain was recorded as the call reason. Recommended outcome and subsequent use of services were determined using the continuous urgent care pathways (CUPs) database which records single episodes of care spanning multiple services. We determined the number of services involved, the proportion of patients with inpatient admission, those with an admission for an 'acute-and-serious' diagnosis, and the association between the triage call recommendation and these outcomes.

RESULTS

There were 102 822 CUPs identified, with 1251 different combinations of services. The most common pathway was an NHS24 call then attendance at a primary care out-of-hours (PCOOH) centre, accounting for 38 643 (37.6%) CUPs. 9060 (8.8%) CUPs ended with hospital admission, 3030 (3.0%) the result of an 'acute-and-serious' diagnosis. 8453 (8.2%) were given 'self-care' advice and not referred further, while 46.9% ended at PCOOH and 15.2% at ED. 'Asthma, unspecified' was the most frequent 'acute-and-serious' diagnosis. Compared with people given self-care advice, referral to other services had increased odds of inpatient admission (adjusted OR (aOR) for ambulance called 28.7, 95% CI 22.6 to 36.3; for 1-hour in-home general practitioner (GP) visit arranged aOR 36.8, 95% CI 23.2 to 58.5) and for admission with an 'acute-and-serious' diagnosis (aOR ambulance called 23.9, 95% CI 16.2 to 35.4; aOR 1-hour GP visit 48.3, 95% CI 25.5 to 91.6).

CONCLUSION

Chest pain triage by NHS24 appears safe, but care pathways can involve multiple service contacts. While acuity assigned to the call is strongly related to the odds of hospital admission and odds of an 'acute-and-serious' diagnosis, 'overtriage' means few patients are directed to self-care advice.

Embracing complexity with systems thinking in general practitioners' clinical reasoning helps handling uncertainty

Clinical reasoning in general practice is increasingly challenging because of the rise in the number of patients with multimorbidity. This creates uncertainty because of unpredictable interactions between the symptoms from multiple medical problems and the patient's personality, psychosocial context and life history. Case analysis may then be more appropriately managed by systems thinking than by hypothetic-deductive reasoning, the predominant paradigm in the current teaching of clinical reasoning. Application of "systems thinking" tools such as causal loop diagrams allows the patient's problems to be viewed holistically and facilitates understanding of the complex interactions. We will show how complexity levels can be graded in clinical reasoning and demonstrate where and how systems thinking can have added value by means of a case history.

Thresholds, rules and defensive strategies: how physicians learn from their prior diagnosis-related experiences

Background Health professionals are encouraged to learn from their errors. Determining how primary care physicians (PCPs) react to a case, in which their original diagnosis differed from the final outcome, could provide new insights on how they learn from experiences. We explored how PCPs altered their diagnostic evaluation of future patients after cases where the originally assumed diagnosis turned out to be wrong. Methods We asked German PCPs to complete an online survey where they described how the patient concerned originally presented, the subsequent course of events and whether they would change their diagnostic work-up of future patients. Qualitative methods were used to analyze narrative text obtained by this survey. Results A total of 29 PCPs submitted cases, most of which were ultimately found to be more severe than originally assumed. PCPs (n = 27) reflected on changes to their subsequent clinical decisions in the form of general maxims (n = 20) or more specific rules (n = 11). Most changes would have resulted in a lower threshold for investigations, referral and/or a more extensive collection of diagnostic information. PCPs decided not only to listen more often to their intuition (gut feelings), but to also practice more analytical reasoning. Participants felt the need for change of practice even if no clinical standards had been violated in the diagnosis of that case. Some decided to resort to defensive strategies in the future. Conclusions We describe mechanisms by which physicians calibrate their decision thresholds, as well as their cognitive mode (intuitive vs. analytical). PCPs reported the need for change in clinical practice despite the absence of error in some cases.

Predicting Coronary Artery Disease in Primary Care: Development and Validation of a Diagnostic Risk Score for Major Ethnic Groups in Southeast Asia

BACKGROUND

Coronary artery disease (CAD) risk prediction tools are useful decision supports. Their clinical impact has not been evaluated amongst Asians in primary care.

OBJECTIVE

We aimed to develop and validate a diagnostic prediction model for CAD in Southeast Asians by comparing it against three existing tools.

DESIGN

We prospectively recruited patients presenting to primary care for chest pain between July 2013 and December 2016. CAD was diagnosed at tertiary institution and adjudicated. A logistic regression model was built, with validation by resampling. We validated the Duke Clinical Score (DCS), CAD Consortium Score (CCS), and Marburg Heart Score (MHS).

MAIN MEASURES

Discrimination and calibration quantify model performance, while net reclassification improvement and net benefit provide clinical insights.

KEY RESULTS

CAD prevalence was 9.5% (158 of 1658 patients). Our model included age, gender, type 2 diabetes mellitus, hypertension, smoking, chest pain type, neck radiation, Q waves, and ST-T changes. The C-statistic was 0.808 (95% CI 0.776-0.840) and 0.815 (95% CI 0.782-0.847), for model without and with ECG respectively. C-statistics for DCS, CCS-basic, CCS-clinical, and MHS were 0.795 (95% CI 0.759-0.831), 0.756 (95% CI 0.717-0.794), 0.787 (95% CI 0.752-0.823), and 0.661 (95% CI 0.621-0.701). Our model (with ECG) correctly reclassified 100% of patients when compared with DCS and CCS-clinical respectively. At 5% threshold probability, the net benefit for our model (with ECG) was 0.063. The net benefit for DCS, CCS-basic, and CCS-clinical was 0.056, 0.060, and 0.065.

CONCLUSIONS

PRECISE (Predictive Risk scorE for CAD In Southeast Asians with chEst pain) performs well and demonstrates utility as a clinical decision support for diagnosing CAD among Southeast Asians.

Interactional implications of either/or-questions during telephone triage of callers with chest discomfort in out-of-hours primary care: A conversation analysis

OBJECTIVE

To explore the interactional implications of either/or-questions on the interaction between people who call out-of-hours services in primary care (OHS-PC) and triage nurses who use a decision support tool called the 'Netherlands Triage Standard' (NTS) during telephone triage.

METHODS

A qualitative study of 68 triage conversations at six Dutch OHS-PC. Patients called the OHS-PC with symptoms, e.g. chest discomfort, suggestive of acute coronary syndrome. Using conversation analysis, we identified two categories of multiple-choice either/or-questions that indicated interactional difficulties, shown in hesitation markers within callers' responses.

RESULTS

Our analysis shows that interactional difficulties mainly arise when (i) questions are poorly designed by the triage nurse; or (ii) when the caller's complaints are ambiguously presented reflecting patient's difficulties to verbalize them (e.g. "not feeling well").

CONCLUSION

The way NTS displays key diagnostic options encourages triage nurses to use multiple-choice either/or-questions. More awareness among triage nurses is needed on undesirable implications of either/or-questions on the interaction.

PRACTICE IMPLICATIONS

We recommend changing the NTS display of diagnostic options and to use questions with fewer options in order to decrease the chance of formulating ambiguous questions soliciting unclear responses. Furthermore, asking content questions when complaints are ambiguously formulated may specify the presentation of complaints.

[Chest pain]

Chest pain is a common symptom for which patients present to their primary care provider. Patients with acute chest pain pose a diagnostic challenge for the general practitioner since a wide range of diagnoses are possible, ranging from life-threatening acute myocardial infarction and pulmonary artery embolism to the far more frequent and harmless muscular tension belonging to the group of chest wall syndromes, as well as gastrointestinal causes such as gastroesophageal reflux disease. The clinical evaluation of patients with acute chest pain is based on a thorough clinical assessment by the physician, including a physical examination and medical history, irrespective of the location of the examination. This is followed by further technical examinations, such as a 12-lead electrocardiogram, and targeted laboratory diagnostics with point-of-care tests, including troponin and D‑dimer tests. Diagnostic pathways and score systems, such as the Marburg Heart Score, have been specially developed to enable patient assessment and provide orientation in the primary care setting.

Diagnostic accuracy of FeNO [fractional exhaled nitric oxide] and asthma symptoms increased when evaluated with a superior reference standard

OBJECTIVES

The objective of the study is to determine the impact of changing reference standards (RS), namely spirometry vs. whole-body plethysmography (WBP), on estimation of the diagnostic accuracy of fractional exhaled nitric oxide (FeNO) and clinical signs and symptoms (CSS) as index tests regarding asthma diagnosis.

STUDY DESIGN AND SETTING

This was a diagnostic study conducted in 393 patients attending a private practice of pneumologists with complaints suspicious of asthma. First, the index tests were compared with the diagnostic results of spirometry in terms of forced expiratory volume in the first second (FEV₁) responsiveness. Second, the index tests were compared with the results of WBP in terms of specific airway resistance and FEV₁ responsiveness. Areas under the curve (AUC) were compared with a generalized estimating equation approach based on binary logistic regression.

RESULTS

FeNO values and CSS 'wheezing' and 'allergic rhinitis' showed higher specificities (P < 0.001) and sensitivities (not significant) when evaluated with WBP; also, Youden indices increased in these CSS (P < 0.05). AUC of FeNO in combination with 'wheezing' and 'allergic rhinitis' when WBP was used as RS (AUC = 0.724; 95% confidence interval 0.672 to 0.776) was higher compared with spirometry as RS (AUC = 0.654; 95% confidence interval 0.585 to 0.722) (P < 0.001).

CONCLUSION

In case of asthma, superior RS led to more favorable assessment of index tests. FeNO measurement might have been underestimated in some previous studies.

Chest discomfort at night and risk of acute coronary syndrome: cross-sectional study of telephone conversations

BACKGROUND

During telephone triage, it is difficult to assign adequate urgency to patients with chest discomfort. Considering the time of calling could be helpful.

OBJECTIVE

To assess the risk of acute coronary syndrome (ACS) in certain time periods and whether sex influences this risk.

METHODS

Cross-sectional study of 1655 recordings of telephone conversations of patients who called the out-of-hours services primary care (OHS-PC) for chest discomfort. Call time, patient characteristics, symptoms, medical history and urgency allocation of the triage conversations were collected. The final diagnosis of each call was retrieved at the patient's general practice. Absolute numbers of patients with and without ACS were plotted and risks per hour were calculated. The risk ratio of ACS at night (0 to 9 am) was calculated by comparing to the risk at other hours and was adjusted for gender and age.

RESULTS

The mean age of callers was 58.9 (standard deviation ±19.5) years, 55.5% were women and, in total, 199 (12.0%) had an ACS. The crude risk ratio for an ACS at night was 1.80 (confidence interval 1.39-2.34, P < 0.001): 2.33 (1.68-3.22, P < 0.001) for men and 1.29 (0.83-1.99, P = 0.256) for women. The adjusted risk ratio for ACS of all people at night was 1.82 (1.07-3.10, P = 0.039).

CONCLUSIONS

Patients calling the OHS-PC for chest discomfort between 0 and 9 am have almost twice a higher risk of ACS than those calling other hours, a phenomenon more evident in men than in women. At night, dispatching ambulances more 'straightaway' could be considered for these patients with chest discomfort.

TRIAL NUMBER

NTR7331.

Utilization of diagnostic resources and costs in patients with suspected cardiac chest pain

AIMS

Non-acute chest pain is a common complaint and can be caused by various conditions. With the rising healthcare expenditures of today, it is necessary to use our healthcare resources effectively. This study aims to give insight into the diagnostic effort and costs for patients with non-acute chest pain.

METHODS AND RESULTS

Financial data of patients without a cardiac history from 4 hospitals (January 2012-October 2018), who were registered with the national diagnostic code 'No cardiac pathology' (ICD-10 Z13.6), 'Chest wall syndrome' (ICD-10 R07.4) or 'stable angina pectoris' (ICD-10 I20.9) were extracted. In total, 74.091 patients were included for analysis and divided into the following final diagnosis groups: No cardiac pathology: N = 19.688 (age 53±18), 46% male), Chest wall syndrome: N = 40.858 (age 56±15), 45% male), and stable angina pectoris: N = 13.545 (age 67±11), 61% male). A total of approximately €142,7 million was spent during diagnostic work-up. The total expenditure during diagnostic effort was €1.97, €8.13, and €10.7 million respectively for no cardiac pathology, chest wall syndrome, and stable AP per year. After 8 years follow up ≥ 95% of the patients diagnosed with no cardiac pathology or chest wall syndrome had an (cardiac) ischemic free survival.

CONCLUSION

The diagnostic expenditure and clinical effort to ascertain non-cardiac chest pain is high. We should define what we as society find acceptable as 'assurance costs' with an increasing pressure on the healthcare system and costs.

Limited reliability of experts' assessment of telephone triage in primary care patients with chest discomfort

OBJECTIVE

Root cause analyses of serious adverse events (SAE) in out-of-hours primary care (OHS-PC) often point to errors in telephone triage. Such analyses are, however, hampered by hindsight bias. We assessed whether experts, blinded to the outcome, recognize (un)safety of triage of patients with chest discomfort, and we quantified inter-rater reliability.

STUDY DESIGN AND SETTING

This is a case-control study with triage recordings from 2013-2017 at OHS-PC. Cases were missed acute coronary syndromes (ACSs, considered as SAE). These cases were age- and gender-matched 1:8 with the controls, sampled from the remainder of people calling for chest discomfort. Fifteen experts listened to the recordings and rated the safety of triage. We calculated sensitivity and specificity of recognizing an ACS and the intraclass correlation.

RESULTS

In total, 135 calls (15 SAE, 120 matched controls) were relistened. The experts identified ACSs with a sensitivity of 0.86 (95% CI: 0.71-0.95) and a specificity of 0.51 (95% CI: 0.43-0.58). Cases were rated significantly more often as unsafe than the controls (73.3% vs. 22.5%, P < 0.001). The inter-rater reliability for safety was poor: ICC 0.16 (95% CI: 0.00-0.32).

CONCLUSIONS

Blinded experts rated calls of missed ACSs more often as unsafe than matched control calls, but with a low level of agreement among the experts.

Correlation between global longitudinal strain and SYNTAX score in coronary artery disease evaluation

BACKGROUND

Speckle tracking echocardiography may allow the evaluation of myocardial systolic and diastolic dynamics across different physiologic and pathologic conditions beyond traditional echocardiographic techniques. The use of STE longitudinal strain in identification and risk stratification of CAD has good reproducibility and accuracy. The study aims to detect the relationship between SYNTAX score and global longitudinal peak systolic strain (GLPSS) in patients undergoing coronary angiography, with no history of myocardial infarction.

RESULTS

The study included 70 symptomatic patients suspected to have chronic coronary syndrome aging 20-80 years (excluding those with significant structural heart disease). All patients underwent clinical evaluation, surface ECG, laboratory assessment, transthoracic echocardiographic (TTE), color TDI tracings, two-dimensional speckle tracking, and conventional coronary angiography with SYNTAX score calculation. Patients were divided into 3 groups based on the results of the coronary angiogram: normal CAD on angiogram (n = 10, control group), low SS (n = 25, SS < 22), and high SS (n = 35, SS ≥ 22). The mean age was 55 ± 9.6 years; 54% were males; two third of patients were hypertensive; 52% were diabetic; high percentage of high syntax score were noticed among males, diabetic patients, and smokers; and also low mean of GLS was noticed among diabetic patients and smokers. There was a statistically significant positive correlation between syntax score and each of LVEDD and LVESD and, on the other hand, statistically significant negative correlation between syntax score and each of E/A, GLS, AP2LS, AP3LS, and AP4LS was noticed. Peak GLS cutoff value of 17.8 and 16.5 showed 84% and 93% sensitivity and 70% and 91% specificity to detect high and low syntax score, respectively.

CONCLUSION

2D longitudinal strain analysis has incremental diagnostic value over visual assessment during echocardiography in predicting significant coronary artery disease; GLS may offer a potential sensitive tool to detect significant CAD.

Rationale and design of a cohort study evaluating triage of acute chest pain in out-of-hours primary care in the Netherlands (TRACE)

The aims of this study are (1) to evaluate the performance of current triage for chest pain; (2) to describe the case mix of patients undergoing triage for chest pain; and (3) to identify opportunities to improve performance of current Dutch triage system for chest pain. Chest pain is a common symptom, and identifying patients with chest pain that require urgent care can be quite challenging. Making the correct assessment is even harder during telephone triage. Temporal trends show that the referral threshold has lowered over time, resulting in overcrowding of first responders and emergency services. While various stakeholders advocate for a more efficient triage system, careful evaluation of the performance of the current triage in primary care is lacking. TRiage of Acute Chest pain Evaluation in primary care (TRACE) is a large cohort study designed to describe the current Dutch triage system for chest pain and subsequently evaluate triage performance in regard to clinical outcomes. The study consists of consecutive patients who contacted the out-of-hours primary care facility with chest pain in the region of Alkmaar, the Netherlands, in 2017, with follow-up for clinical outcomes out to August 2019. The primary outcome of interest is ‘major event’, which is defined as the occurrence of death from any cause, acute coronary syndrome, urgent coronary revascularization, or other high-risk diagnoses in which delay is inadmissible and hospitalization is necessary. We will evaluate the performance of the triage system by assessing the ability of the triage system to correctly classify patients regarding urgency (accuracy), the proportion of safe actions following triage (safety) as well as rightfully deployed ambulances (efficacy). TRACE is designed to describe the current Dutch triage system for chest pain in primary care and to subsequently evaluate triage performance in regard to clinical outcomes.

Gender differences in the presentation of chest pain in obstructive coronary artery disease: results from the Korean Women's Chest Pain Registry

BACKGROUND/AIMS

Chest pain in patients with obstructive coronary artery disease (OCAD) is affected by several social factors. The gender-based differences in chest pain among Koreans have yet to be investigated.

METHODS

The study consecutively enrolled 1,549 patients (male/female, 514/1,035; 61 ± 11 years old) with suspected angina. The predictive factors for OCAD based on gender were evaluated.

RESULTS

Men experienced more squeezing type pain on the left side of chest, while women demonstrated more dull quality pain in the retrosternal and epigastric area. After adjustment for risk factors, pain in the retrosternal area (odds ratio [OR], 1.491; 95% confidence interval [CI], 1.178 to 1.887) and aggravation by exercise (OR, 2.235; 95% CI, 1.745 to 2.861) were positively associated with OCAD. In men, shorter duration (OR, 1.581; 95% CI, 1.086 to 2.303) and dyspnea (OR, 1.610; 95% CI, 1.040 to 2.490) increased the probability for OCAD, while left-sided chest pain suggested a low probability for OCAD (OR, 0.590; 95% CI, 0.388 to 0.897). In women, aggravation by emotional stress (OR, 0.348; 95% CI, 0.162 to 0.746) and dizziness (OR, 0.457; 95% CI, 0.246 to 0.849) decreased the probability for OCAD.

CONCLUSION

This is the first study to focus on gender differences in chest pain among Koreans with angina. Symptoms with high probability for OCAD were different between sexes. Our findings suggest that patient's medical history in pretest assessment for OCAD should be individualized considering gender.

CT coronary angiography in asymptomatic male patients with high atherosclerosis risk: Is it justified?

PURPOSE

To study the necessity of coronary artery screening with computerized tomography coronary angiography (CTCA) in asymptomatic male patients.

MATERIAL AND METHODS

A total of 226 asymptomatic male patients aged over 50 years were included in this prospective study, according to a clinical protocol approved by the Heraklion University Hospital's Ethics Committee. All participants had at least 3 or more known atherosclerosis risk factors. All patients had none or normal noninvasive cardiological tests in the past and had no contraindications for CTCA. All patients gave their informed consent after being notified regarding contrast medium and radiation dose risks.

RESULTS

Significant stenoses were found in 52 asymptomatic males (23%). Out of them, 38 male patients underwent invasive coronography and 14 patients were lost in follow-up. In 18 patients, no lesions were found (47.4%). In the other 20 (52.6%) patients, 28 lesions were found. Stent placement was performed in 11 patients, bypass surgery was proposed in 3 patients, and in another 6 patients conservative treatment was suggested. Patients with findings in CTCA were more likely to have a family history of coronary artery disease, compared to patients with normal CTCA (P < 0.05 by using Fischer's Exact Test). Sensitivity of CTCA for significant stenosis was 74.3% with a specificity of 62%.

CONCLUSION

CTCA may be used to screen for clinically significant coronary artery disease (CAD) in asymptomatic male patients, particularly those with positive family history or potentially high-risk patients with >3 risk factors for CAD.

Optimisation of telephone triage of callers with symptoms suggestive of acute cardiovascular disease in out-of-hours primary care: observational design of the Safety First study

INTRODUCTION

In the Netherlands, the 'Netherlands Triage Standard' (NTS) is frequently used as digital decision support system for telephone triage at out-of-hours services in primary care (OHS-PC). The aim of the NTS is to guarantee accessible, efficient and safe care. However, there are indications that current triage is inefficient, with overestimation of urgency, notably in suspected acute cardiovascular disease. In addition, in primary care settings the NTS has only been validated against surrogate markers, and diagnostic accuracy with clinical outcomes as the reference is unknown. In the Safety First study, we address this gap in knowledge by describing, understanding and improving the diagnostic process and urgency allocation in callers with symptoms suggestive of acute cardiovascular disease, in order to improve both efficiency and safety of telephone triage in this domain.

METHODS AND ANALYSIS

An observational study in which 3000 telephone triage recordings (period 2014-2016) will be analysed. Information is collected from the recordings including caller and symptom characteristics and urgency allocation. The callers' own general practitioners are contacted for the final diagnosis of each contact. We included recordings of callers with symptoms suggestive of acute coronary syndrome (ACS) or transient ischaemic attack (TIA)/stroke. With univariable and multivariable logistic regression analyses the diagnostic accuracy of caller and symptom characteristics will be analysed in terms of predictive values with urgency level, and ACS and TIA/stroke as outcomes, respectively. To further improve our understanding of the triage process at OHS-PC, we will carry out additional studies applying both quantitative and qualitative methods: (i) case-control study on serious adverse events (SAE), (ii) conversation analysis study and (iii) interview study with triage nurses.

ETHICS AND DISSEMINATION

The Medical Ethics Committee Utrecht, the Netherlands endorsed this study (National Trial Register identification: NTR7331). Results will be disseminated at scientific conferences, regional educational sessions and publication in peer-reviewed journals.

A Nationwide Flash-Mob Study for Suspected Acute Coronary Syndrome

PURPOSE

Our primary objective was to evaluate the Marburg Heart Score (MHS), a clinical decision rule, or to develop an adapted clinical decision rule for family physicians (FPs) to safely rule out acute coronary syndrome (ACS) in patients referred to secondary care for suspected ACS. The secondary objective was to evaluate the feasibility of using the flash-mob method, an innovative study design, for large-scale research in family medicine.

METHODS

In this 2-week, nationwide, prospective, observational, flash-mob study, FPs collected data on possible ACS predictors and assessed ACS probability (on a scale of 1-10) in patients referred to secondary care for suspected ACS.

RESULTS

We collected data for 258 patients in 2 weeks by mobilizing approximately 1 in 5 FPs throughout the country via ambassadors. A final diagnosis was obtained for 243 patients (94.2%), of whom 45 (18.5%) received a diagnosis of ACS. Sex, sex-adjusted age, and ischemic changes on electrocardiography were significantly associated with ACS. The sensitivity of the MHS (cut-off ≤2) was 75.0%, specificity was 44.0%, positive predictive value was 24.3%, and negative predictive value was 88.0%. For the FP assessment (cut-off ≤5), these test characteristics were 86.7%, 41.4%, 25.2%, and 93.2%, respectively.

CONCLUSIONS

For patients referred to emergency care, ACS could not be safely ruled out using the MHS or FP clinical assessment. The flash-mob study design may be a feasible alternative research method to investigate relatively simple, clinically relevant research questions in family medicine on a large scale and over a relatively short time frame.

Chest pain in general practice: a systematic review of prediction rules

OBJECTIVE

To identify and assess the performance of clinical decision rules (CDR) for chest pain in general practice.

DESIGN

Systematic review of diagnostic studies.

DATA SOURCES

Medline/Pubmed, Embase/Ovid, CINAHL/EBSCO and Google Scholar up to October 2018.

STUDY SELECTION

Studies that assessed CDRs for intermittent-type chest pain and for rule out of acute coronary syndrome (ACS) applicable in general practice, thus not relying on advanced laboratory, computer or diagnostic testing.

REVIEW METHODS

Reviewers identified studies, extracted data and assessed the quality of the evidence (using Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2)), independently and in duplicate.

RESULTS

Eight studies comprising five CDRs met the inclusion criteria. Three CDRs are designed for rule out of coronary disease in intermittent-type chest pain (Gencer rule, Marburg Heart Score, INTERCHEST), and two for rule out of ACS (Grijseels rule, Bruins Slot rule). Studies that examined the Marburg Heart Score had the highest methodological quality with consistent sensitivity (86%-91%), specificity (61%-81%) and positive (23%-35%) and negative (97%-98%) predictive values (PPV and NPV). The diagnostic performance of Gencer (PPV: 20%-34%, NPV: 95%-99%) and INTERCHEST (PPV: 35%-43%, NPV: 96%-98%) appear comparable, but requires further validation. The Marburg Heart Score was more sensitive in detecting coronary disease than the clinical judgement of the general practitioner. The performance of CDRs that focused on rule out of ACS were: Grijseels rule (sensitivity: 91%, specificity: 37%, PPV: 57%, NPV: 82%) and Bruins Slot (sensitivity: 97%, specificity: 10%, PPV: 23%, NPV: 92%). Compared with clinical judgement, the Bruins Slot rule appeared to be safer than clinical judgement alone, but the study was limited in sample size.

CONCLUSIONS

In general practice, there is currently no clinical decision aid that can safely rule out ACS. For intermittent chest pain, several rules exist, of which the Marburg Heart Score has been most extensively tested and appears to outperform clinical judgement alone.

Protection against the overuse and underuse of health care - methodological considerations for establishing prioritization criteria and recommendations in general practice

BACKGROUND

Initiatives such as "Choosing Wisely" in the USA and "Smarter Medicine" in Switzerland have published lists of widely overused health care services. The German initiative "Choosing Wisely Together (Gemeinsam Klug Entscheiden)" follows this example. The goal of our study was to prioritize important recommendations against the overuse and underuse of health care services. The final list of recommendations will be published in the German guideline "Protection against the overuse and underuse of health care".

METHODS

First, a multidisciplinary expert panel established a catalogue of prioritization criteria. Second, we extracted all the recommendations from evidence- and consensus-based German College of General Practice and Family Medicine (DEGAM) guidelines and National Health Care Guidelines (NVL). Third, the recommendations were rated by two independent panels (general practitioners and other health care professionals involved/not involved in guideline development). The prioritization process was finalized in a consensus conference held by DEGAM's Standing Guideline Committee (SLK).

RESULTS

Eleven prioritization criteria were established. A total of 782 recommendations were extracted and rated by 98 physicians and other health care professionals in a survey. In the voting process, more than 80% of the recommendations were eliminated. After the final consensus conference, twelve recommendations from DEGAM guidelines, nine DEGAM addenda and 17 NVL recommendations were chosen for inclusion in the guideline, for a total of 38 recommendations.

CONCLUSION

The selection procedure proved helpful in identifying the highest priority recommendations with which to combat the overuse and underuse of health care services. To date, in Germany there has been no attempt to compile such a list by using a systematic and transparent methodology. Hence, the guideline that results from this process can fill an important gap.

Point-of-care testing in primary care patients with acute cardiopulmonary symptoms: a systematic review

BACKGROUND

Point-of-care tests (POCT) can assist general practitioners (GPs) in diagnosing and treating patients with acute cardiopulmonary symptoms, but it is currently unknown if POCT impact relevant clinical outcomes in these patients.

OBJECTIVE

To assess whether using POCT in primary care patients with acute cardiopulmonary symptoms leads to more accurate diagnosis and impacts clinical management.

METHODS

We performed a systematic review in four bibliographic databases. Articles published before February 2016 were screened by two reviewers. Studies evaluating the effect of GP use of POCT on clinical diagnostic accuracy and/or effect on treatment and referral rate in patients with cardiopulmonary symptoms were included.

RESULTS

Our search yielded nine papers describing data from seven studies, on the clinical diagnostic accuracy of POCT in a total of 2277 primary care patients with acute cardiopulmonary symptoms. Four papers showed data on GP use of D-dimer POCT in pulmonary embolism (two studies); two studies on Troponin T in acute coronary syndrome; one on heart-type fatty acid-binding protein (H-FABP) in acute coronary syndrome; one on B-type natriuretic peptide (BNP) in heart failure; one on 3-in-1 POCT (Troponin T, BNP, D-dimer) in acute coronary syndrome, heart failure and/or pulmonary embolism. Only one study assessed the effect of GP use of POCT on treatment initiation and one on actual referral rates.

CONCLUSION

There is currently limited and inconclusive evidence that actual GP use of POCT in primary care patients with acute cardiopulmonary symptoms leads to more accurate diagnosis and affects clinical management. However, some studies show promising results, especially when a POCT is combined with a clinical decision rule.

The Diagnosis of Chronic Coronary Heart Disease

BACKGROUND

Chronic coronary heart disease (CHD) and acute myocardial infarction are endemic conditions. In Germany, an estimated 900 000 cardiac catheterizations were performed in the year 2014, and a percutaneous intervention was carried out in 40% of these procedures. It would be desirable to lessen the number of invasive diagnostic procedures while preserving the reliability of diagnosis. In this article, we present the updated recommendations of the German National Care Guideline for Chronic CHD with regard to diagnostic evaluation.

METHODS

Updated recommendations for the diagnostic evaluation of chronic CHD were developed on the basis of existing guidelines and a systematic literature review and approved by a formal consensus process.

RESULTS

8-11% of patients with chest pain who present to a general practitioner and 20-25% of those who present to a cardiologist have chronic CHD. General practitioners should estimate the probability of CHD with the Marburg Heart Score. Specialists can use detailed tables for determining the pre-test probability of CHD; if this lies in the range of 15% to 85%, then non-invasive tests should be primarily used for evaluation and treatment planning. If the pretest probability is less than 15%, other potential causes should be ruled out first. If it is over 85%, the presence of CHD should be presumed and treatment planning should be initiated. Coronary angiography is needed only if therapeutic implications are expected (revascularization). Psychosocial risk factors for the development and course of CHD and the patient's quality of life should be regularly assessed as well.

CONCLUSION

Non-invasive testing and invasive coronary angiography should be used only if their findings are expected to have therapeutic implications. Psychosocial risk factors, the quality of life, and adherence to treatment are important components of these patients' diagnostic evaluation and long-term care.

Frequency of chest pain in primary care, diagnostic tests performed and final diagnoses

OBJECTIVE

Observational study of patients with chest pain in primary care: determination of incidence, referral rate, diagnostic tests and (agreement between) working and final diagnoses.

METHODS

118 general practitioners (GPs) in the Netherlands and Belgium recorded all patient contacts during  2weeks. Furthermore, patients presenting with chest pain were registered extensively. A follow-up form was filled in after 30 days.

RESULTS

22 294 patient contacts were registered. In 281 (1.26%), chest pain was a reason for consulting the GP (mean age for men 54.4/women 53 years). In this cohort of 281 patients, in 38.1% of patients, acute coronary syndrome (ACS) was suspected at least temporarily during consultation, 40.2% of patients were referred to secondary care and 512 diagnostic tests were performed by GPs and consulted specialists. Musculoskeletal pain was the most frequent working (26.1%) and final diagnoses (33.1%). Potentially life-threatening diseases as final diagnosis (such as myocardial infarction) accounted for 8.4% of all chest pain cases. In 23.1% of cases, a major difference between working and final diagnoses was found, in 0.7% a severe disease was initially missed by the GP.

CONCLUSION

Chest pain was present in 281 patients (1.26% of all consultations). Final diagnoses were mostly non-life-threatening. Nevertheless, in 8.4% of patients with chest pain, life-threatening underlying causes were identified. This seems reflected in the magnitude and wide variety of diagnostic tests performed in these patients by GPs and specialists, in the (safe) overestimation of life-threatening diseases by GPs at initial assessment and in the high referral rate we found.

Chest pain for coronary heart disease in general practice: clinical judgement and a clinical decision rule

BACKGROUND

The Marburg Heart Score (MHS) is a simple, valid, and robust clinical decision rule assisting GPs in ruling out coronary heart disease (CHD) in patients presenting with chest pain.

AIM

To investigate whether using the rule adds to the GP's clinical judgement.

DESIGN AND SETTING

A comparative diagnostic accuracy study was conducted using data from 832 consecutive patients with chest pain in general practice.

METHOD

Three diagnostic strategies were defined using the MHS: diagnosis based solely on the MHS; using the MHS as a triage test; and GP's clinical judgement aided by the MHS. Their accuracy was compared with the GPs' unaided clinical judgement.

RESULTS

Sensitivity and specificity of the GPs' unaided clinical judgement was 82.9% (95% confidence interval [CI] = 72.4 to 89.9) and 61.0% (95% CI = 56.7 to 65.2), respectively. In comparison, the sensitivity of the MHS was higher (difference 8.5%, 95% CI = -2.4 to 19.6) and the specificity was similar (difference -0.4%, 95% CI = -5.3 to 4.5); the sensitivity of the triage was similar (difference -1.5%, 95% CI = -9.8 to 7.0) and the specificity was higher (difference 11.6%, 95% CI = 7.8 to 15.4); and both the sensitivity and specificity of the aided clinical judgement were higher (difference 8.0%, 95% CI = -6.9 to 23.0 and 5.8%, 95% CI = -1.6 to 13.2, respectively).

CONCLUSION

Using the Marburg Heart Score for initial triage can improve the clinical diagnosis of CHD in general practice.

[National disease management guidelines (NVL) for chronic CAD : What is new, what is particularly important?]

Coronary heart disease (CAD) is widespread and affects 1 in 10 of the population in the age group 40-79 years in Germany. The German national management guidelines on chronic CAD comprise evidence and expert-based recommendations for the diagnostics of chronic stable CAD as well as for interdisciplinary/multidisciplinary therapy and care of patients with stable CAD. The focus is on the diagnostics, prevention, medication therapy, revascularization, rehabilitation, general practitioner care and coordination of care. Recommendations for optimizing cooperation between all medical specialties involved as well as the definition of mandatory and appropriate measures are essential aims of the guidelines both to improve the quality of care and to strengthen the position of the patient.

Chest pain in general practice: Frequency, management, and results of encounter

Objective:

Chest pain is a common reason for an encounter in general practice. The present investigation was set out to characterize the consultation rate of chest pain, accompanying symptoms, frequency of diagnostic and therapeutic interventions, and results of the encounter.

Materials and Methods:

Cross-sectional data were collected from randomly selected patients in the German Sächsische Epidemiologische Studie in der Allgemeinmedizin 2 (SESAM 2) and analyzed from the Dutch Transition Project.

Results:

Overall, 270 patients from the SESAM 2 study consulted a general practitioner due to chest pain (3% of all consultations). Chest pain was more frequent in people aged over 45 years. The most common diagnostic interventions were physical examination, electrocardiogram at rest and analysis of blood parameters. For the majority of cases, the physicians arranged a follow-up consultation or prescribed drugs. The transition project documented 8117 patients reporting chest pain with a frequency of 44.5/1000 patient years (1.7% of all consultations). Physical examination was also the most common diagnostic intervention, and physician's advice the most relevant therapeutic one.

Conclusion:

The most common causes for chest pain were musculoskeletal problems followed by cardiovascular diseases. Ischemic heart disease, psychogenic problems, and respiratory diseases each account for about 10% of the cases. However, acutely dangerous causes are rare in general practice.

Presentation of Coronary Artery Disease in a Chiropractic Clinic: A Report of 2 Cases

OBJECTIVE

The purpose of this report is to describe 2 patients with coronary artery disease presenting with musculoskeletal symptoms to a chiropractic clinic.

CLINICAL FEATURES

A 48-year-old male new patient had thoracic spine pain aggravated by physical exertion. A 61-year-old man under routine care for low back pain experienced a secondary complaint of acute chest pain during a reevaluation.

INTERVENTION AND OUTCOME

In both cases, the patients were strongly encouraged to consult their medical physician and were subsequently diagnosed with coronary artery disease. Following their diagnoses, each patient underwent surgical angioplasty procedures with stenting.

CONCLUSION

Patients may present for chiropractic care with what appears to be musculoskeletal chest pain when the pain may be generating from coronary artery disease necessitating medical and possibly emergency care.

Clinical assessment of patients with chest pain; a systematic review of predictive tools

Background

The clinical assessment of patients with chest pain of recent onset remains difficult. This study presents a critical review of clinical predictive tools for the assessment of patients with chest pain.

Methods

Systematic review of observational studies and estimation of probabilities of coronary artery disease (CAD) in patients with chest pain. Searches were conducted in PubMed, Embase, Scopus, and Web of Science to identify studies reporting tools, with at least three variables from clinical history, physical examination or ECG, produced with multivariate analysis, to estimate probabilities of CAD in patients with chest pain of recent onset, published from inception of the database to the 31^st July 2015. The references of previous relevant reviews were hand searched. The methodological quality was assessed with standard criteria. Since the incidence of CAD has changed in the past few decades, the date of publication was acknowledged to be relevant in order to use the tool in clinical practice, and more recent papers were considered more relevant. Probabilities of CAD according to the studies of highest quality were estimated and the evidence provided was graded.

Results

Twelve papers were included out of the 19126 references initially identified. The methodological quality of all of them was high. The clinical characteristics of the chest pain, age, past medical history of cardiovascular disease, gender, and abnormalities in the ECG were the predictors of CAD most commonly reported across the studies. The most recent papers, with highest methodological quality, and most practical for use in clinical settings, reported prediction or exclusion of CAD with area under the curve 0.90 in Primary Care, 0.91 in Emergency department, and 0.79 in Cardiology. These papers provide evidence of high level (1B) and the recommendation to use their results in the management of patients with chest pain is strong (A).

Conclusions

The risk of CAD can be estimated on clinical grounds in patients with chest pain in different clinical settings with high accuracy. The estimation of probabilities of CAD presented in these studies could be used for a better management of patients with chest pain and also in the development of future predictive tools.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0196-4) contains supplementary material, which is available to authorized users.

Coronary artery disease in the military patient

Ischaemic heart disease is the most common cause of sudden death in the UK, and the most common cardiac cause of medical discharge from the Armed Forces. This paper reviews current evidence pertaining to the diagnosis and management of coronary artery disease from a military perspective, encompassing stable angina and acute coronary syndromes. Emphasis is placed on the limitations inherent in the management of acute coronary syndromes in the deployed environment. Occupational issues affecting patients with coronary artery disease are reviewed. Consideration is also given to the potential for coronary artery disease screening in the military, and the management of modifiable cardiovascular disease risk factors, to help decrease the prevalence of coronary artery disease in the military population.

Clinical value of chest pain presentation and prodromes on the assessment of cardiovascular disease: a cohort study

OBJECTIVES

The recognition of coronary artery disease (CAD) among patients who report chest pain remains difficult in primary care. This study investigates the association between chest pain (specified, unspecified or musculoskeletal) and prodromes (dyspepsia, fatigue or dyspnoea), with first-ever acute CAD, and increased longer term cardiovascular risk.

DESIGN

Cohort study.

SETTING

Anonymised clinical data recorded electronically by general practitioners from 140 primary care surgeries in London (UK) between April 2008 and April 2013.

PARTICIPANTS

Data were extracted for all patients aged 30 years and over at the beginning of the study period, registered in the surgeries.

MAIN OUTCOME MEASURES

Clinical data included chest pain, dyspepsia, dyspnoea and fatigue, first-ever CAD and long-term cardiovascular risk (QRisk2). Regression models were used to analyse the association between chest pain together with prodromes and CAD and QRisk2≥20%.

RESULTS

354,052 patients were included in the study. 4842 patients had first-ever CAD of which 270 reported chest pain in the year before the acute event. 257,019 patients had QRisk2 estimations. Chest pain was associated with a higher risk of CAD. HRs: 21.12 (16.68 to 26.76), p<0.001; 7.51 (6.49 to 8.68), p<0.001; and 1.84 (1.14 to 3.00), p<0.001 for specified, unspecified and musculoskeletal chest pain. Dyspepsia, dyspnoea or fatigue was also associated with a higher risk of CAD. Chest pain of all subtypes, dyspepsia and dyspnoea were also associated with an increased 10-year cardiovascular risk of 20% or more.

CONCLUSIONS

All patients with chest pain, including those with atypical symptoms, require careful assessment for acute and longer term cardiovascular risk. Prodromes may have independent diagnostic value in the estimation of cardiovascular disease risk.

Duration analysis for coronary artery disease patients with chronic chest pain: an output from saudi arabia

INTRODUCTION

Coronary artery disease (CAD) is a persistent public health problem worldwide. Chest pain is one of the perceptible symptoms of the same disease. Literature has found acute chest pain as plausible risk factors for CAD. Nevertheless, none of the study has estimated duration from chronic chest pain to the diagnosis of CAD. The objective of the study was to estimate duration from chronic chest pain to CAD and to assess impact of risk factors on same duration.

METHODS

Data were obtained from community based study on 17,232 Saudi adults. History of patients about onset of chest pain and other risk factors were inquired. Descriptive measures were obtained by Kaplan-Meier curve. Effect of demographic and clinical factors was assessed by Cox regression models.

RESULTS

Out of 24% patients with chest pain, 21% diagnosed with CAD. The average duration was 5 years. About 12% of patients with chest pain diagnosed with CAD after one year. Advancing age, female gender, no exercise and reduced high density lipoprotein (HDL) were significantly hazardous predictors throughout duration from chest pain to diagnosis of CAD.

CONCLUSION

The duration from chest pain to CAD was 5 years. Age, gender, exercise and HDL can be variables of concern to deteriorate hazards of CAD for patients with chest pain.

Management of non-traumatic chest pain by the French Emergency Medical System: Insights from the DOLORES registry

BACKGROUND

The early recognition of acute coronary syndromes is a priority in health care systems, to reduce revascularization delays. In France, patients are encouraged to call emergency numbers (15, 112), which are routed to a Medical Dispatch Centre where physicians conduct an interview and decide on the appropriate response. However, the effectiveness of this system has not yet been assessed.

AIM

To describe and analyse the response of emergency physicians receiving calls for chest pain in the French Emergency Medical System.

METHODS

From 16 November to 13 December 2009, calls to the Medical Dispatch Centre for non-traumatic chest pain were included prospectively in a multicentre observational study. Clinical characteristics and triage decisions were collected.

RESULTS

A total of 1647 patients were included in the study. An interview was conducted with the patient in only 30.5% of cases, and with relatives, bystanders or physicians in the other cases. A Mobile Intensive Care Unit was dispatched to 854 patients (51.9%) presenting with typical angina chest pains and a high risk of cardiovascular disease. Paramedics were sent to 516 patients (31.3%) and a general practitioner was sent to 169 patients (10.3%). Patients were given medical advice only by telephone in 108 cases (6.6%).

CONCLUSIONS

Emergency physicians in the Medical Dispatch Centre sent an effecter to the majority of patients who called the Emergency Medical System for chest pain. The response level was based on the characteristics of the chest pain and the patient's risk profile.

Diagnostic performance of reproducible chest wall tenderness to rule out acute coronary syndrome in acute chest pain: a prospective diagnostic study

OBJECTIVES

Acute chest pain (ACP) is a leading cause of hospital emergency unit consultation. As there are various underlying conditions, ranging from musculoskeletal disorders to acute coronary syndrome (ACS), thorough clinical diagnostics are warranted. The aim of this prospective study was to assess whether reproducible chest wall tenderness (CWT) on palpation in patients with ACP can help to rule out ACS.

METHODS

In this prospective, double-blinded diagnostic study, all consecutive patients assessed in the emergency unit at the University Hospital Zurich because of ACP between July 2012 and December 2013 were included when a member of the study team was present. Reproducible CWT on palpation was the initial step and was recorded before further examinations were initiated. The final diagnosis was adjudicated by a study-independent physician.

RESULTS

121 patients (60.3% male, median age 47 years, IQR 34-66.5 years) were included. The prevalence of ACS was 11.6%. Non-reproducible CWT had a high sensitivity of 92.9% (95% CI 66.1% to 98.8%) for ACS and the presence of reproducible CWT ruled out ACS (p=0.003) with a high negative predictive value (98.1%, 95% CI 89.9% to 99.7%). Conversely non-reproducible CWT ruled in ACS with low specificity (48.6%, 95% CI 38.8% to 58.5%) and low positive predictive value (19.1%, 95% CI 10.6% to 30.5%).

CONCLUSIONS

This prospective diagnostic study supports the concept that reproducible CWT helps to rule out ACS in patients with ACP in an early stage of the evaluation process. However, ACS and other diagnoses should be considered in patients with a negative CWT test.

TRIAL REGISTRATION NUMBER

ClinicalTrial.gov: NCT01724996.

Chest pain out-of-hours - an interview study of primary care physicians' diagnostic approach, tolerance of risk and attitudes to hospital admission

Background

Acute chest pain constitutes a considerable diagnostic challenge outside hospitals. This will often lead to uncertainty in choosing the right management, and the physicians’ approach may be influenced by their knowledge of diagnostic measures and their tolerance of risk. The aim of this study was to investigate primary care physicians’ diagnostic approach, tolerance of risk and attitudes to hospital admission in patients with acute chest pain out-of-hours in Norwegian primary care.

Methods

Data were registered prospectively from four Norwegian casualty clinics. Data from structured telephone interviews with 100 physicians shortly after a consultation with a patient presenting at the casualty clinic with “chest pain” were analysed. Tolerance of risk was measured by the Pearson Risk Scale and the Tolerance of Risk Scale, the latter developed for this study.

Results

“Patient history and symptoms” was considered the most important, and “negative ECG” and “effect of sublingual nitroglycerine” the least important aspects in the diagnostic approach. There were no significant differences in length of experience or gender when testing “risk avoiders” against the rest. Almost all physicians felt that their risk assessment out-of-hours was reasonably good, and felt reasonably safe, but only 50% agreed with the statement “I don’t worry about my decisions after I’ve made them”. Concerning chest pain patients only, 51% of the physicians were worried about complaints being made about them, 75% agreed that admitting someone to hospital put patients in danger of being “over-tested”, and 51% were more likely to admit the patient if the patient herself wanted to be admitted.

Conclusions

Physicians working out-of-hours showed considerable differences in their diagnostic approach, and not all physicians diagnose patients with chest pain according to current guidelines and evidence. Continuous medical education must focus on the diagnostic approach in patients with chest pain in primary care and empowerment of physicians through training and emphasis on risk assessment and “tolerance of risk”.

Diagnostic characteristics and prognoses of primary-care patients referred for clinical exercise testing: a prospective observational study

Background

Evaluation of angina symptoms in primary care often includes clinical exercise testing. We sought to identify clinical characteristics that predicted the outcome of exercise testing and to describe the occurrence of cardiovascular events during follow-up.

Methods

This study followed patients referred to exercise testing for suspected coronary disease by general practitioners in the County of Jämtland, Sweden (enrolment, 25 months from February 2010). Patient characteristics were registered by pre-test questionnaire. Exercise tests were performed with a bicycle ergometer, a 12-lead electrocardiogram, and validated scales for scoring angina symptoms. Exercise tests were classified as positive (ST-segment depression >1 mm and chest pain indicative of angina), non-conclusive (ST depression or chest pain), or negative. Odds ratios (ORs) for exercise-test outcome were calculated with a bivariate logistic model adjusted for age, sex, systolic blood pressure, and previous cardiovascular events. Cardiovascular events (unstable angina, myocardial infarctions, decisions on revascularization, cardiovascular death, and recurrent angina in primary care) were recorded within six months. A probability cut-off of 10% was used to detect cardiovascular events in relation to the predicted test outcome.

Results

We enrolled 865 patients (mean age 63.5 years, 50.6% men); 6.4% of patients had a positive test, 75.5% were negative, 16.4% were non-conclusive, and 1.7% were not assessable. Positive or non-conclusive test results were predicted by exertional chest pain (OR 2.46, 95% confidence interval (CI) 1.69-3.59), a pathologic ST-T segment on resting electrocardiogram (OR 2.29, 95% CI 1.44-3.63), angina according to the patient (OR 1.70, 95% CI 1.13-2.55), and medication for dyslipidaemia (OR 1.51, 95% CI 1.02-2.23). During follow-up, cardiovascular events occurred in 8% of all patients and 4% were referred to revascularization. Cardiovascular events occurred in 52.7%, 18.3%, and 2% of patients with positive, non-conclusive, or negative tests, respectively. The model predicted 67/69 patients with a cardiovascular event.

Conclusions

Clinical characteristics can be used to predict exercise test outcome. Primary care patients with a negative exercise test have a very low risk of cardiovascular events, within six months. A predictive model based on clinical characteristics can be used to refine the identification of low-risk patients.